Attach Fee* Instructions Follow Name(s) Plaintiff(s), versus DEPARTMENT OF REVENUE, State of Oregon, Defendant. IN THE OREGON TAX COURT MAGISTRATE DIVISION Income Tax , ) , ) ) ) ) ) ) Case No. _______________ (for court use only) ) ) COMPLAINT SECTION 1. Plaintiff(s) appeal(s) from Oregon tax assessed or refund denied for tax year(s) ______________________________________________________________________________. Taxes are classified as (circle one): Personal Corporate Withholding Timber Tobacco Other________________________________________________________________________. *Attach a Copy of the Order, Letter, Notice or Other Document Being Appealed.* SECTION 2. Defendant (Department of Revenue) is in error because: ___________________ _____________________________________________________________________________. SECTION 3. Plaintiff(s) request(s) the following relief: _______________________________ _____________________________________________________________________________. The filing of this complaint by a representative identified in ORS 305.230 is recognized by the court as authorizing that representative to receive information from the Department of Revenue that would otherwise be confidential under ORS 314.835. __________________________________ Plaintiff’s Name (PRINT) (must be completed) _________________________________________ Plaintiff’s Name (PRINT) (must be completed) Representative’s Name (PRINT)*** _________________________________________ Representative’s Oregon Bar or License Number __________________________________ Mailing Address (must be completed) Mailing Address __________________________________ City, State, Zip (must be completed) City, State, Zip __________________________________ Telephone Number (daytime) (must be completed) Telephone Number (daytime) __________________________________ Signature (must be completed unless represented) Representative’s Signature(s) (if above completed) _____________________________________ Signature (must be completed unless represented) Date Signed _________________________________________ _________________________________________ Date Signed (must be completed unless represented) Email Address* _________________________________________ Email Address** (must be completed unless represented) ** Notices of Proceedings will be sent by email (Please adjust your email filters to allow emails from: TAX.OJIN.Notice.Mailer@ojd.state.or.us ) * The fee is $75 through September 30, 2011; the fee is $240 on and after October 1, 2011. *** If your representative is not an Oregon attorney, an Authorization to Represent must be completed and submitted with this Complaint. An authorization form is available on request or on our website at http://courts.oregon.gov/Tax/. Rev. 08/11W American LegalNet, Inc. www.FormsWorkFlow.com How to File an Income Tax Appeal with the Magistrate Division To Appeal, You must Do All of the Following Within Your Appeal Period: (1) Fill out all sections of the Complaint form; AND (2) Sign the Complaint (all named plaintiffs must sign the Complaint); AND (3) Date the Complaint; AND (4) Attach to the Complaint a copy of the order or notice you are appealing; AND (5) Submit the fee* (make check payable to “Oregon Tax Court”); *AND (6) Make two copies of the Complaint and attachments. Mail the original Complaint and attachments plus one complete copy to the court. Keep one complete copy for yourself. (7) To determine the date a mailed Complaint is “filed,” the court is required to use the date shown by the U.S. post office cancellation mark stamped on the envelope in which the Complaint is mailed. See ORS 305.418. The court’s mailing address is: Oregon Tax Court Magistrate Division 1163 State Street Salem, Oregon 97301-2563 (503) 986-5650 or toll free: 1-800-773-1162 The court is located at: 1241 State Street, Third Floor (3R), Salem, Oregon *The fee is $75 through September 30, 2011; the fee is $240 on and after October 1, 2011. The Oregon Legislature may modify fees between publications of this form. The Oregon Tax Court website lists the current fee. A form to show proof of inability to pay the fee and request waiver of the fee is available upon request or on the court website at http://courts.oregon.gov/tax Instructions for Completing the Complaint Form HEADING. Fill in the name(s) of the plaintiff(s) (the taxpayer(s)). All taxpayers named on the document appealed must be named and must sign the complaint. SECTION 1. Insert the year or years being appealed. Circle the appropriate type of tax you are appealing. *Attach a copy of the order, letter, notice, or other document being appealed.* SECTION 2. Explain why you believe the tax assessed against you, or the denial of your refund, is wrong. (If more space is needed, attach additional pages.) SECTION 3. Explain what you want the court to do for you. MEDIATION: In all cases, either party may request mediation. Mediation is court-facilitated negotiation. The purpose is to help the parties obtain a clearer understanding of the merits of each position and help them reach a mutually acceptable agreement. A party may request mediation at any time. Rev. 08/11W American LegalNet, Inc. www.FormsWorkFlow.com