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Clear Form Application for Proration of Property Taxes For county use only Due to Damage by Fire or Act of God Date received Rte` Oregon Revised Statutes(ORS)308.425 1 DI 2:7\Z ) ore-- Instructions: rLInstructions: •Application for proration of property taxes may be made for the tax year of the property damage/destruction.If approved,this may reduce the amount of tax due or result in a tax refund.The tax year is from July 1 to June 30. •Your application must be filed within 60 days of the damage or by June 30 of the tax year in which the damage occurred,whichever is later. •File your application with the county tax collector of the county in which your damaged property is located. Applicant's name Phone Dennis Engblom 5035098895 Mailing address Email(optional) 23707 Santiam Way SE dennis.engblom@gmail.c City State ZIP code Mehama OR 97358-9421 Location and description of damaged or destroyed property Assessor's account number 351430,56934,56-925- Q_,E S l , Location of property(if different from above) Section Township Range Tax lot number 1143 Oq 2C 600/ Description of personal property 09-08-2020 Date of damage Cause of damage Beachie Creek Wildfire D Fire(attach fire department report) IN Act of God(describe): Damage occurred to ®Land RI Building ®Personal property ®Manufactured structure Describe damage Total destruction of home and one outbuilding.99%personal property destroyed. Application for proration of tax ®I am applying to have the above property examined for proration of property taxes per ORS 308.425.Application must be submitted within 60 days of damage or June 30,whichever is later. Whether my property is damaged or destroyed will be determined by the County Assessor's office.If the assessor determines my property is only dam- aged,I must notify the tax collector of the date that the damage is repaired.Such notice will serve to inform the tax collector of their duty to calculate and finalize the tax proration. 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's e,correct,and complete. X vv, /l� z7fr© z-0 Applicant's signature Date —Applicant will be notified of the county's decision— For tax collector's use only For assessor's use only Date received: 2-12-2! Clerk:rtf Date received: i t- ii_20 Clerk: IN 4 o(p Damaged property: This year Land and improvements: Real market value(RMV)before RMV after �r Date rebuild complete: Months prorated:,��L�[ fire/act of God: 1131( ) fire/act of God: 113 7(0J ^V A�� `i�� Assessed value(AV)Jzef re Value Amou u n fire/act of God: 94 jR 0 percent of loss: n Destroyed proper �`tC,`'� r��0'� This year Personal property: A 0.‘,......Glontns RMV before RMV after Noprorated: fire/act of God: fire/act of God: AV before Value Amount of adjustment/refund: fire/act of God: percent of loss: Remarks: 1 1 Date property visited: 0 Damaged 0 Destroyed I andOn1V1 160-310-083(Rev.12-15)