Form Ref-01 - Property Refund Request - 2009 Page 2
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2Property Refund Request Form
Page 2
SECTION IV - ACCOUNT CREDIT INFORMATION
10. Indicate the reason there is a credit on this account. Check one of the following:
Overpayment. Indicate the amount: $ _________________________
Date of payment:________/________/________
K
Reduction in assessed property value.
MONTH
DAY
YEAR
K
The reduction is due to a court order. List date of order:
________/________/________
K
You may be requested to provide a copy of the court order.
MONTH
DAY
YEAR
Abatement or Exemption (e.g., STAR, SCRIE, DRIE, J51, etc.).
K
Cancellation of a charge already paid.
K
Other (Please explain): ___________________________________________________________________________
K
Unsure of reason for the credit.
K
SECTION V - 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 for the above-listed period(s), 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 arising from this refund. Any refund paid is subject to audit and recoupment. I under-
stand that any willful false statements 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
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