Form Rp-6371-Bar - Lake Ontario And Connected Waterways Assessment Relief Act Complaint On Real Property Assessment Page 2

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Page 2 of 2 RP-6371-BAR (7/17)
Part 3 – Designate a representative
(optional)
I,
, as complainant, 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 all purposes of reviewing the assessment of my real property, as it
appears on the
(year) tentative assessment roll.
Printed name of authorized representative
Employer identification number
Authorized
Signature of authorized representative
Signature of owner
representative
information
Address of authorized person
Telephone number
Date
(
)
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.
Signature of owner (or representative)
Date
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:
Name
All concur except:
against
abstain
absent
Name
against
abstain
absent
Decision by
Assessment roll
Claimed reduction
Board of Assessment Review
Assessment
reduction
%
%
%
Date notification mailed to complainant

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