Certificate Of Error Refund Application Form 2015
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Maria Pappas
Cook County Treasurer
CERTIFICATE OF ERROR REFUND APPLICATION
Fill in each blank below (P lease print clearly)
STEP
1
Property Index Number (PIN)
Volume
Tax Year
CR/JR Number
Certificate of Error Number
P lease indicate w here the check w ill be m ailed.
STEP
2
Taxpayer Name
In care of
Address
Daytime Phone
City/State/Zip
Email
I hereby c ertify, under penalty of law, t hat I a m l egally and equitably entitled to t he refund based on the referenced Certificate of Error; t hat I have not
previously received all or any part of a refund from the Office of the Cook County Treasurer or any other party for the same year, Property Index Number (PIN)
and reason; and that, if I am not so entitled, I will indemnify and hold the Office of the Cook County Treasurer harmless from any and all adverse claims to
such refund, including costs and attorney’s fees.
Signature
Date
P lease review the reverse side of this form and attach any and all proof of paym ent available, such as:
STEP
nd
Copy of the front side of the cancelled check(s) used to pay the 2
Installment taxes for the tax year in question.
•
3
nd
If the refund amount is more than the 2
Installment amount paid, you will need to provide a copy of the front of
st
nd
the canceled check(s) used to pay both the 1
and 2
Installments.
•
Copies of the teller receipt if paid by cash for the tax year in question.
•
A letter (or letters) from any mortgage company, title company or other third-party who submitted payment that
includes the following: (1) Property Index Number, (2) taxpayer’s name, (3) amount(s) paid, and (4) date(s) of
payment(s).
M ail this com pleted application (w ith proof of paym ent attached) to the Treasurer’s Office address below .
Incomplete applications or those with insufficient proof of payment may be returned. Additional information on proof of
payment can be found on the reverse side of this form. Please contact us at , or call us at
(312) 443-5100 with any questions.
MAIL ALL APPLICATIONS TO:
Cook County Treasurer
Refund Department
118 N. Clark Street – Room 112
Chicago, IL 60602
For Office Use Only
PROPERTY INDEX NUMBER (PIN) _________________________________ VOLUME ________ TAX YEAR _____________
CR/JR NUMBER _________________________________ CERTIFICATE OF ERROR NUMBER ________________________
1
ST
INSTALLMENT
2
ND
INSTALLMENT
Amount Due:
____________________
Amount Due:
____________________
Amount Paid:
____________________
Amount Paid:
____________________
Total Tax DUE: ____________________
Total Tax PAID: ____________________
Accepted By: ____________________ Date: ____________________
Proofed By: _____________________
Date: ____________________
Entered By: _____________________
Date: ____________________
Last Revised 1/2015
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