OFFICE OF THE AUDITOR-CONTROLLER/
TREASURER/TAX COLLECTOR
Attn: Penalty Cancellation Review
268 West Hospitality Lane, First Floor
San Bernardino, CA 92415
www.MyTaxCollector.com
REQUEST FOR PENALTY CANCELLATION - COVID-19 IMPACT
THIS REQUEST FOR PENALTY CANCELLATION WILL NOT BE CONSIDERED WITHOUT FULL PAYMENT OF TAXES DUE. THIS
REQUEST IS ONLY APPLICABLE FOR PROPERTY TAXES WITH A DELINQUENT PENALTY DATE FROM MARCH 4, 2020,
THROUGH MAY 6, 2021.
Please check property type:
Residential real property owned and
occupied by taxpayer
R
eal property owned and operated by
a taxpayer that qualifies as a small
business under the SBA’s Regulations
Business Personal Property owned
by a taxpayer that qualifies as a small
business under the SBA’s Regulations
Applicant Name:
Assessor’s Parcel Number (APN): Bill Number:
Mailing Address:
City: State: Zip Code:
Property Address:
City: State: Zip Code:
Daytime Phone No. ( )
Email Address (Optional):
Reason for Request for Penalty Cancellation COVID-19 Impact:
Economic Hardship:
COVID-19 Related Health Concerns:
Other:
Please fully describe the reason(s) for making this request. The reason for this request must be associated with an economic hardship
and/or an inability to tender payment of taxes due to the COVID-19 pandemic, or any local, state or federal response to COVID-19.
The failure to pay timely was due to circumstances beyond my control, occurred in spite of the exercise of ordinary care, there was no willful
neglect involved, and was for the following reason(s). Attach additional pages if necessary.
I declare and certify under penalty of perjury that the information contained in the foregoing statement is true and correct and that I am signing
as the assessee of record or his/her authorized agent.
Print & Sign Date
PL
EASE REVIEW THIS IMPORTANT INFORMATION BEFORE
COMPLETING AND SUBMITTING YOUR REQUEST
Under Executive Order N-61-20, a taxpayer may file a claim with the tax collector for relief of penalties on property
taxes for owner occupied residential real property or real property owned and operated by a taxpayer that qualifies
as a small business under the Small Business Administration’s Regulations, Code of Federal Regulations, Title
13, section 121.201. The taxpayer must satisfactorily demonstrate to the tax collector that they have suffered
economic hardship and/or an inability to tender payment of taxes due to the COVID-19 pandemic, or any local,
state or federal response to COVID-19 for the request to be approved.
Tax
es must not have been delinquent as of March 4, 2020. Taxes being paid under an installment plan of
redemption shall not be considered delinquent if all plan payments were current as of March 4, 2020.
Business personal property was not included for relief in the Executive Order N-61-20, however, relief may
be provided based on the application and information
This penalty cancellation request must be submitted by May 6, 2021.
If after review, the penalty cancellation is denied, the assessee will receive notice that the penalties are due
and payable.
I
NSTRUCTIONS:
1. Complete the Applicant Information section, provide a full description of the reason(s) for making the
request, sign and date the form. The form must be signed by an owner whose name appears on the title
of the property or his/her authorized agent. Please print or write legibly using blue or black ink.
2. Mail the completed and signed form, along with payment (penalties excluded) to:
OFFICE OF THE AUDITOR-CONTROLLER/
TREASURER/TAX COLLECTOR
Attn: Penalty Cancellation Review
268 West Hospitality Lane, First Floor
San Bernardino, CA 92415-0360