Refund Claim For Overpaid Fees Form - Connecticut Secretary Of State printable pdf download

Refund Claim For Overpaid Fees Form - Connecticut Secretary Of State

Secretary of the State

30 Trinity Street

Hartford, CT 06106

Refund Claim for Overpaid Fees

Refunds will not be processed unless they comply with Connecticut General Statutes Sec. 3-99,

which state in part that the amount must be in excess of $5.00 and not have accrued for more

than one year in order to be refunded.

Additionally, a copy of the ftont and back of the negotiated check will be required in order to

process a refund claim along with any supporting documentation such as a rejection letter or

notice of money on account.

The following information is required to accurately process a refund:

am the only person or entity having a valid claim to

the monies being held on account at the Office of the Secretary of the State.

I request check be made payable as follows:

[name of person or entity]

[mailing address, include your reference # if desired]

Work order #:

Customer ID #:

Processing #:

Refund Amount:

The foregoing is made under the penalties of false statement:

Type/print name:

Title:

Signed:

Date:

Below is for use by the Office of the Secretary of the State only

Orig Dep #

Dep Date

Approved by

PL#

Amount

Refund Claim For Overpaid Fees Form - Connecticut Secretary Of State