Real Estate Transfer Tax Claim For Refund

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New York State Department of Taxation and Finance
For office use only
Real Estate Transfer Tax Claim for Refund
Name of claimant
Name of representative or person to contact
Telephone number
(
)
Social security number
Employer identification number
Firm name, if applicable
Address of claimant
Address of person to contact
City, village or post office
State
ZIP code
City, village or post office
State
ZIP code
Location of property conveyed
(list each lot separately; attach additional sheets if necessary)
Address
County
Address
County
Date of transfer
(mm/dd/yyyy)
1 Amount of tax paid by claimant/assignor ..................................... 1.
Refund assignment: If the refund
is to be paid to someone other than
2 Amount of tax due ........................................................................ 2.
the person primarily liable for the
tax, mark an X in this box and see
3 Refund requested
..................................
3.
instructions on back ...........................
(subtract line 2 from line 1)
Explanation: Give a full explanation below, including all facts on which your claim is based. Attach additional pages if necessary, and submit a copy
of all documentation necessary to substantiate your claim. In addition, if the Form TP-584, Combined Real Estate Transfer Tax Return, Credit Line
Mortgage Certificate, and Certification of Exemption from the Payment of Estimated Personal Income Tax, was filed with a recording officer rather
than directly with the Tax Department, submit a copy of the receipt provided by the recording officer at the time of payment.
Certification: I
,
, the claimant named above, or partner, officer, or other authorized
representative of the claimant, certify that the information contained in this claim is true and correct to the best of my knowledge, that no prior claim
for a refund of the whole or any part of the amount on line 3 has been filed, and that no part has previously been refunded to the claimant or any
assignee, except as specified herein.
Signature
Title or relationship to claimant
Date
TP-592.2 (4/13)

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