Declaration Of Representative

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DECLARATION OF REPRESENTATIVE
Property Owner(s) Name(s) as it appears on the Change of Value Notice
Property Owner’s Mailing Address (Street, PO Box, City, State, Zip Code)
Property Owner’s Telephone Number
hereby appoints the following individual, corporation, limited liability company,
organization, firm or partnership
Individual Representatives Name and Title
If applicable, provide Corporation, Limited Liability Company, Organization, Firm or Partnership
Name
Representative’s Mailing Address (Street, PO Box, City, State, Zip Code)
Representative’s Telephone Number
To represent the above named property owner before the State Board of Tax Appeals
pursuant to the Board’s rules and regulations for property located in
_______________________ County for the _____________________ tax year(s).
____________________________________________________
_____________________________
Signature of Property Owner
Date
If signing on behalf of a corporation, limited liability company, organization, firm or partnership,
provide below the printed name and title of person signing.
____________________________________________________
______________________________
Printed Name
Title
BTA Revised 07/2014

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