Request for Waiver of Fees,
Interest, Penalties, and Taxes
INSTRUCTIONS FOR COMPLETION & SUBMISSION OF FORM:
1. This form is to be used by the taxpayer who, claimi
ng an error or omission on the part of the County, is seeking a waiver of fees,
interest and penalties of real or personal property liability.
2. A separate waiver form
is required for each tax bill.
3. If taxpayer finds insufficient space on this form to p
etition for waiver, additional attachments from the taxpayer will be accepted
along with this form.
4. In accordance with the Clay County Mi
ssouri Code of Ordinances, this form may be changed as needed, in reflection of any policy
or ordinance changes.
5. This Re
q
uest for Waiver of Fees
,
Interest
,
Penalties
,
and Taxes is sub
j
ect to RSMo
§§
52.230
,
52.240 and 139.031.
Waiver Case #
Date Received:
Due to County Error
Prescribed by the Clay County Commission
FORM W
-
2008
-
ORD
-
31
Form W-2008-ORD-31
Telephone Number Fax Number
Third Party Designee Name and Address Telephone Number
Taxpayer Signature Authorizing Third Party Designee Date Signed by Taxpayer (Month, Day, Year)
E-Mail Address
If a Third Party Designee is authorized to receive the Taxpayer’s information and assist with this request, complete the following:
Description of Property Parcel Number (if Real Estate)
Check applicable: (Taxpayer MUST check at least one)
Taxpayer pays property taxes directly
Mortgage Company withholds taxes from monthly payments
taxpayer makes to Mortgage Company
Other
Real Estate
Personal Property
THIS FORM IS TO BE SIGNED, DATED AND RETURNED WITH COPY OF TAX BILL SHOWING PROOF OF ERROR(S),
OMISSION(S) AND ANY PAYMENT(S) FOR THE TAX YEAR(S) FOR WHICH ADJUSTMENT OR REFUND REQUEST IS CLAIMED.
1
2
3
4
5
6
7
8
9
10
Assessment
Year
Date
Paid
Amount of
Property
Taxes
Amount of
Fees
Amount of
Penalties
Amount of
Interest
Amount of
Special
Assessments
Costs
Total
(3+4+5+6+7+8)
Reason and/or Purpose for Request for Waiver (Please attach any documentation including copy of tax bill, mortgage statement and other
documentation such as personal property tax declaration, detailing County error or omission. Use additional pages or attachments if needed
to detail reason.)
Incorrect Parcel Information Incorrect Property Description Incorrect Taxpayer Information
Incorrect Assessment Valuation Incorrect Tax Amount on Statement Electronic Payment Error
Mortgage Related Error Error in Determination of Taxes Owed Other
Please describe in detail County error or omission
.
Section 4 Reason for Re
q
uested Waiver on Fees, Interest, Penalties and Tax Liabilit
y
* Waiver request applicable ONLY if there is clear and convincing evidence that the County made an error or omission in determining taxes
owed by taxpayer. RSMo 52.230
Contested
Amount*
Section 3 Amount of Re
q
uested Waiver on Fees, Interest, Penalties and Tax Liabilit
y
Name of Mortgage Company(If Mortgage Company pays real estate
property taxes through escrow)
Address of Property (numbe
r and street, city, state and ZIP code)
Section 2 Pro
p
ert
y
Information
E-Mail Address
Mailing Address of Taxpayer (nu
mber and street, city, state and ZIP code)
Name of Taxpayer
Section 1 Tax
p
a
y
e
r
Information
Form W-2008-ORD-31
Waiver request applicable ONLY if there is clear and convincing evidence that the County made an error
or omission in determining taxes owed by taxpayer. RSMo 52.230
Authorized Signature of Taxpayer
Printed Name of Signatory
Signature of Clay County Assessor
Signature of Clay County Collector Date Signed (Month, Day, Year)
Section 7 Cla
y
Count
y
Commission Verification
We, the Clay County Commission, hereby verify that this Request for Waiver of Fees,
Interest, Penalties and Taxes form was filed with the Commission on the date received.
We, the Clay County Commission, as governing body of this County:
Approved Denied
- the taxpayer’s Request for Waiver of Fees, Interest, Penalties and Taxes.
Date Signed (Month, Day, Year)
Signature of Western Commissioner
Date Attested (Month, Day, Year)
ATTEST:
Signature of County Clerk By:
Signature of Eastern Commissioner
Signature of Presiding Commissioner
Statement of Justification:
.
Waiver Amount Approved:
$
.
County error will generate a waiver or refund in the amount of: Interest $ Penalties $ .
I, the Clay County Collector, hereby verify that I have reviewed this Request for Waiver of Fees, Interest, Penalties and Taxes form, and:
Agree – Subject to County Commission approval
Disagree
–
Subject to County Commission approval
To Be Com
p
leted b
y
Collecto
r
Date Signed (Month, Day, Year)
Statement of Justification:
.
I, the Clay County Assessor, hereby verify that I have reviewed this Request for Waiver of Fees, Interest, Penalties and Taxes form, and:
Agree – Subject to County Commission approval
Disagree
–
Subject to County Commission approval
To Be Com
p
leted b
y
Assessor
Section 6 Assessor and Collecto
r
Waiver Re
q
uest
V
eri
f
ication
Mailing Address of Taxpayer (number and street, city, state and ZIP code)
Title
Date Signed (Month, Day, Year)
By signing below, I hereby petition for an adjustment or refund as provisioned in RSMo § 139.031, and amounts as detailed in § 3 of this
petition. I hereby certify and declare under penalty of perjury that the foregoing is true and correct; and that the amounts herein petitioned
are correct and that no part of this contestation has been previously refunded to the taxpayer, or to any other person or entity for the
taxpayer’s benefit; and, if as Petitioner or Representative acting on behalf of the Taxpayer, that I am duly authorized thereof to act on the
Taxpayer’s behalf. I understand that any person who makes a false entry or statement upon this record shall be subject to fines and/or
imprisonment.
Section 5 Tax
p
a
y
er Certification
Form W-2008-ORD-31
Section 8 Tax
p
a
y
er Additional Information or Attachments
Please provide any additional information, detail or attachments
