Form Ref-01 - Property Refund Request - 2015 (Page 3 of 3) in pdf

Property Refund Request Form

Page 3

SECTION V - CREDIT OPTION INFORMATION - Continued

PARTIAL REFUND

I want $ __________________ of my credit to be transferred to the below parcel, which I own, and the balance to be

refunded to me in the form of a check. (Please note that credits that resulted from an attorney action generally may not

be transferred and must be refunded.) Please indicate the amount to be transferred, the account type to where the money

should be transferred (see #3 in the instructions for more information), and the period to which the money should be

applied below.

Borough _______________________ Block __________________________ Lot __________________________

AMOUNT

ACCOUNT TYPE

PERIOD

$ ___________________________________ _______________________________ _______

_______

$ ___________________________________ _______________________________ _______

_______

$ ___________________________________ _______________________________ _______

_______

$ ___________________________________ _______________________________ _______

_______

SECTION VI - CERTIFICATION

SIGN HERE IF YOU PAID THE CHARGES FOR WHICH YOU ARE REQUESTING A REFUND

I am the payer of, or an officer of the cooperative management board or a duly authorized employee of the corpora-

tion that paid a tax or charge upon which this request is based. I certify that all statements made and information

provided, to the best of my knowledge, is true and correct. If the City of New York verifies that a credit exists for this

property, I consent that the refund be paid to the above-named individual or entity, and I agree to release the City of

New York from any claims arising from this refund and to reimburse the city for any costs resulting from claims aris-

ing from this refund. Any refund paid is subject to audit and recoupment. I understand that any willful false state-

ments made herein may subject me to the penalties described in the Penal Law.

____________________________________

____________

Signature

Print Name

Date

SIGN HERE IF YOU DID NOT PAY THE CHARGES FOR WHICH YOU ARE REQUESTING A REFUND

I certify that I have been properly authorized by the payer or entity responsible for payment of the tax or charge upon

which this claim is based to request a refund and to accept payment on behalf of such party. Any refund paid is sub-

ject to audit and recoupment, and I have so advised the party for whom I am making this application. I certify that all

statements made and information provided on this application are true and correct to the best of my knowledge. I

understand that any willful false statements made herein may subject me to the penalties described in the Penal Law.

____________________________________

____________

Signature

Print Name

Date

Form Ref-01 - Property Refund Request - 2015 Page 3

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