Form Rp-7142 - Complaint On Tentative Special Franchise Assessments Page 4
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4RP-7142 (3/11)
Page 4
PART FOUR: CERTIFICATION
I certify that I have read the foregoing complaint and know the contents thereof, that the facts stated therein are
true and correct to the best of my knowledge, information 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 statements.
Date
Signature/Title
Clear Form
This complaint form and supporting documentation must be mailed/served at least ten (10) days before the
hearing date to:
Darlene A. Maloney
Office of Counsel
New York State Department of Taxation & Finance
W. A. Harriman State Campus
Albany, NY 12227
Please refer to the “Notice of Tentative Special Franchise Full Values” which specifies the complaint
submission deadline. Specific supporting documentation must be provided in accordance with §610 of the Real
Property Tax Law. A copy of the complaint form and documentation must be served on each adverse party. An
affidavit of this service must be filed with the Commissioner at the above address no later than five (5) days
before the hearing date.
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