Form 150-303-075 - Request For Supervisory Review Page 2
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2Supervisory standards continued
Standard 5—“A question of fact exists that is of interest to the department, to which no other standard applies, and which does not
involve valuation judgment.” Explain the issue:
Relief requested—Describe the relief you are requesting, or other pertinent information:
Value information—
Please submit separate value information for each year under consideration.
Real Market Value (RMV)
RMV on tax bill
RMV requested
Assessed Value (AV)
AV on tax bill
AV requested
Land
Buildings
Other
Total
Exception RMV
Total
Declaration
I declare under the penalties for false swearing [ORS 305.990(4)] that I have examined this document, and to the best of my
knowledge, it is true, correct, and complete.
Signature of petitioner or authorized representative
Print or type name
Date
X
Authorization to represent
If you choose to be represented, you can only be represented by a person listed below. All correspondence will be mailed to that person.
I authorize
to represent me before the Department of Revenue.
Signature of petitioner
Print
Date
X
Authorized representative address
My authorized representative is (check one):
City
State
ZIP code
A person licensed or authorized to perform real estate appraisals
in Oregon.
E-mail address
A real estate broker licensed under ORS 696.022.
An attorney licensed to practice in Oregon.
Telephone number
(
)
A public accountant or enrolled agent licensed to practice in Oregon.
My employee regularly employed in tax matters.
Mail to: Property Tax Division
Oregon Department of Revenue
PO Box 14380, Salem OR 97309-5075
150-303-075 (Rev. 04-12)
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