Form Rp-5849-Bar - Superstorm Sandy Assessment Relief Act Complaint On Real Property Assessment Page 3

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Page 3 of 3 RP-5849-BAR (10/13)
Part 3 - Designation of representative to make complaint
I, ________________________________________ , as complainant (or officer thereof) hereby designate
____________________________________ to act as my representative in any and all proceedings before the
board of assessment review of the city/town/village/county of ____________________________ for purposes of
reviewing the assessment of my real property as it appears on the ______ (year) tentative assessment roll of such
assessing unit.
__________________________________
_______________________________________________
Date
Signature of owner (or officer thereof)
Part 4 - Certification
I certify that all statements made on this application are true and correct to the best of my knowledge and belief, and
I understand that the making of any willful false statement of material fact herein will subject me to the provisions of
the Penal Law relevant to the making and filing of false instruments.
Date
Signature of owner (or representative)
Clear Form
Space Below For Use of Board of Assessment Review
Disposition
Change in percentage of reduced assessment
No change in assessment
Reason: _____________________________________________________________________________________
____________________________________________________________________________________________
Vote on complaint
All concur
All concur except: __________________________
against
abstain
absent
Name
__________________________
against
abstain
absent
Name
Decision by
Assessment roll
Claimed reduction
Board of Assessment Review
Assessment reduction
%_______________
%_______________
%_________________________
Date notification mailed to complainant: ________________________________

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