Form Hcd 475.0 - Application For Refund

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STATE OF CALIFORNIA
BUSINESS, TRANSPORTATION AND HOUSING AGENCY
DEPARTMENT OF HOUSING AND COMMUNITY DEVELOPMENT
DIVISION OF CODES AND STANDARDS
REGISTRATION AND TITLING PROGRAM
APPLICATION FOR REFUND
SECTION I.
UNIT DESCRIPTION AND PAYEE INFORMATION
Enter Decal or License Number:
Enter Serial Number:
Enter Date Fees Paid:
Enter County Name:
Enter Name and Address of
Name:
Party Requesting Refund
(Payee)
Street:
City:
State:
Zip:
Enter Registered Owner
Name:
Name and Address (If
Different than Payee)
Street:
City:
State:
Zip:
SECTION II.
CLAIM FOR REFUND AND APPLICANT'S CERTIFICATION
A claim for refund in the amount of $__________________ in fees paid in error or fees not required to be paid to the
Department of Housing and Community Development is hereby requested.
PLEASE STATE BRIEFLY IN THIS SPACE WHY A REFUND IS BEING REQUESTED
I/We certify under penalty of perjury under the laws of the State of California that the foregoing is true and correct.
Executed on
at
Date
City
State
Signature:
DEPARTMENT USE ONLY
Prior Years
Current
Total
PPF
PPF
PPF
=
PPF
Headquarters Approval Clerk
RF
RF
RF
=
RF
Refund Approved By:
ILT
ILT
ILT
ILT
PEN1
PEN1
PEN1
=
PEN1
PEN2
PEN2
PEN2
=
PEN2
(Signature of Manager/Supervisor)
TRF
TRF
TRF
=
TRF
DUPT
DUPT
DUPT
=
DUPT
DUPR
DUPR
DUPR
DUPR
=
ACCOUNTING USE ONLY
SUBD
SUBD
SUBD
=
SUBD
CONF
CONF
CONF
=
CONF
Check Number:
REPO
REPO
REPO
=
REPO
RREG
RREG
RREG
=
RREG
Check Date:
RSF
RSF
RSF
=
RSF
SIT
SIT
SIT
=
SIT
By:
UTP
RT
UTP
RT
UTP
RT
=
UTP
RT
ASF
ASF
ASF
=
ASF
MHP
MHP
MHP
=
MHP
CCP
CCP
CCP
=
CCP
TOTAL
TOTAL
TOTAL
=
TOTAL
HCD 475.0 (11/00)

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