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1 Application for Proration of Property Taxes For county use only Due to Damage by Fire or Act of God Date received Oregon Revised Statutes(ORS)308.425 Instructions: •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 &61hc g L�i�•r��r Zvi- y3G-/33 Mailing addres Email(optional) City State ZIP code diem &,- 6773/ 7 Location and description of damaged or destroyed property Assessor's account number R41013 / 541013 Location of property(if different from above) Section Township Range Tax lot number ' North Fork Road 17AB 09S 2E 700 Description of personal property Lyons, Oregon Date of damage Cause of damage tj Fire(attach fire department report) NAct of God(describe): Damage occurred to Ql Land jl Building .personal property ❑Manufactured structure Describe damage a.cS,`v/ D NOV 0 42.zn Application for proration of tax RX0N GGuhp.sNt�' MP► JESS()B ❑I am applying to have the above property examined for proration of property taxes per ORS 308.425.Application mus 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 is true, correct, and complete. x W(a-y/►'�P Z ,6,011/1--- Applicant's sigdature �U 4 - �a Date —Applicant will be notified of the county's decision— For tax collector's use only For assessor's use only Date received: 1--1?-7-1 Clerk: /3 Date received: /a-/-a O Clerk: /j V 6(, Damaged property: �T/his year Land and improvements: Date rebuild complete: '– Months pro i Real market value(RMV)before RMV after q `r fire/act of God: / 23 7 fire/act of God: !0 6 SO 10 Y� 0 Assessed value(AV)before Value i rtit1�S stikegt, r� fire/act of God: y 5 („c, percent of loss: l) Destroyed prop NGEi \\�� This year Personal property: NO Cr'C Months prorated: RMV before RMV after fire/act of God: fire/act of God: AV before Value Amount of adjustment/refund: ---' fire/act of God: percent of loss: Remarks: Date property visited: /d-/p-,, o, ❑Damaged 9.8eStroyed 10 bvin) 150-310-083(Rev.12-15)