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WATER QUALITY PROTECTION CHARGE APPEAL FORM
Regulated by the Code of Montgomery County Regulation (COMCOR) 19.35.01.07
Montgomery County Department of Environmental Protection

INCLUDE A COPY OF PROPERTY TAX BILL AND SUPPORTING DOCUMENTATION FOR THE APPEAL NOT LATER THAN
SEPTEMBER 30th OF THE YEAR THAT PAYMENT OF THE CHARGE IS DUE.

I am the (check one): * If Authorized Agent, please attach copy of document creating authorization
Property Tax Account No:* Name:*
Premise Address:*
Owner/Agent Address:
Telephone No:* Premise Phone:
E-mail Address:
Upload Documents:*

BASIS FOR APPEAL (PLEASE COMPLETE EACH APPLICABLE SECTION)
Section 1. Incorrect Classification
A. Indicate Correct Classification (check one)



B. Indicate Previous Classification (check one)



Section 2. Incorrect Area Measurements
Provide a summary statement explaining the incorrect area measurement in the box below (use additional sheets of paper if necessary) and attach detailed documentation to support the assertion.
Section 3. Property Not Subject to the Charge under Applicable Law
Provide a summary statement about why your property is not subject to the Charge in the box below (use additional sheets of paper if necessary) and attach detailed documentation to support the assertion.
Section 4. Combine Multiple Property Parcels Into One
Provide a summary statement (including all tax account IDs) about how your properties are contiguous and single-owner in the box below (use additional sheets of paper if necessary) and attach detailed documentation to support the assertion
I hereby certify that the information contained in this request and the supporting documents is true and correct. I am the owner of the above identified property. I also understand that, if approved, this exemption will apply to my account only for the current tax year.

By checking this check box, I *sign this application.
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