Legal Application for Reassessment

LEGAL APPLICATION FOR REASSESSMENT

This Legal Application for Reassessment (the “Application”) is made on this day of , by Applicant Name: with address: , and Respondent Name: with address: .

Recitals

WHEREAS, on or about , the Respondent issued a decision or assessment identified as: ; and

WHEREAS the Applicant believes the decision contains material error(s) in law or fact, or that new evidence has arisen that would materially affect the outcome of the decision; and

WHEREAS the Applicant seeks formal reassessment of the subject decision pursuant to applicable statutory or regulatory authority and the procedural rights afforded to parties.

Now, Therefore

NOW THEREFORE, in consideration of the mutual covenants and representations contained herein and for other good and valuable consideration, the receipt and sufficiency of which are hereby acknowledged, the parties agree as follows:

1. Definitions

For purposes of this Application: “Assessment” means the decision, valuation, charge, or determination specified in decision_reference; “Applicant” means the person or entity named as Applicant Name; “Respondent” means the body or person identified as Respondent Name.

2. Scope of Reassessment Requested

The Applicant hereby requests a reassessment of the Assessment identified above for the assessment period: to .

The reassessment shall be limited to the issues expressly identified in Section 3 below unless otherwise ordered by the deciding authority.

3. Grounds for Reassessment

The Applicant asserts the following grounds as the basis for reassessment (check all that apply and provide detail where requested):

4. Relief Requested

The Applicant requests the following relief (select applicable remedies and quantify where required):

5. Supporting Documents

The Applicant encloses or will file the following documents in support of this Application. Each document listed is a true, complete and accurate copy of the original where applicable:

6. Procedure, Timing and Relief Administration

The Applicant requests that the Respondent set this matter for hearing or determination within days of receipt of this Application. If a hearing is scheduled, the Applicant requests the following accommodations or scheduling preferences:

7. Fees, Costs and Payments

The Applicant acknowledges responsibility for any statutory or administrative fee associated with this Application unless a waiver is granted. The Applicant:

8. Confidentiality and Disclosure

Unless otherwise ordered, all documents filed in support of this Application will be treated in accordance with applicable confidentiality rules. The Applicant requests that the following materials, if any, be treated as confidential and not disclosed to third parties:

9. Notices

All formal notices, filings and communications pertaining to this Application shall be sent to the following addresses for each party:

10. Amendments; Waiver; Counterparts

This Application may be amended or supplemented in writing by the Applicant. No failure or delay by any party in exercising any right under this Application shall operate as a waiver of that right. This Application may be executed in counterparts, each of which shall constitute an original and all of which together shall constitute one and the same instrument.

11. Governing Law; Entire Agreement; Severability

This Application and any dispute arising from it shall be governed by the substantive law of the jurisdiction identified here: .

This Application constitutes the entire written agreement between the parties with respect to the subject matter hereof and supersedes all prior negotiations, proposals, and representations, whether written or oral. If any provision of this Application is held invalid or unenforceable, the remaining provisions shall continue in full force and effect.

12. Certification

The Applicant certifies under penalty of perjury, to the extent applicable, that the statements made in this Application and the attached supporting documents are true, correct and complete to the best of the Applicant’s knowledge, information and belief, and that the Applicant has authority to submit this Application on the matters asserted herein.

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