County Form 17t - Account Of Tax Refund
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1PRESCRIBED BY STATE BOARD OF ACCOUNTS
COUNTY FORM NO. 17T (REV.2002)
APPROVED BY DEPARTMENT OF LOCAL GOVERNMENT FINANCE
________________________ County, Indiana
To ______________________________ Dr.
ON ACCOUNT OF TAX REFUND
______________________________________
Taxing Unit __________________________
DESCRIPTION OF PROPERTY
AMOUNTS PAID
PAID BY TAXPAYER
STMT.
PROC.
CHRG.
DUE DATE
LESS PROP.
LESS
PENALTIES
ITEM
OF INSTALL-
DUPLICATE
TAX REPL.
HOMESTEAD
& INTEREST TOTAL PAID
NO.
DATE PAID
MENT
NO.
GROSS TAX
CREDIT
CREDIT
NET TAX
1
$
$
$
$
$
$
2
3
4
5
6
$
7
Total lines 1 to 6 incl.
$
$
$
$
$
(1)
AMOUNTS PAYABLE
AMOUNT DUE FROM TAXPAYER
STMT.
PROC.
CHRG.
LESS PROP.
LESS
NET TAX
PENALTIES
ITEM
GROSS TAX
TAX REPL.
HOMESTEAD
DUE
& INTEREST TOTAL DUE
NO.
DUE
CREDIT
CREDIT
1a
$
$
$
$
$
$
2a
3a
4a
5a
6a
7a
Total lines 1 to 6 incl.
Claim for Erroneous Payment
100
(Line 7 less Line 7a)
$
$
$
$
$
$
(1)
(2)
(1) This column shows credit due State of Indiana on December Settlement Sheet.
(2) This column includes delinquent penalties and late assessment penalties and interest.
INTEREST DUE CLAIMANT
(To be computed from due date or date of payment, whichever is later)
PERIOD ON WHICH INTEREST IS
INTEREST @ 4% PER
COMPUTED
ITEM
AMOUNT ON WHICH INTEREST IS COMPUTED
ANNUM (Invalid Tax Sale
DAYS
NO.
(TOTAL PAID LESS TOTAL DUE)
YEARS
MONTHS
Interest @ 6%)
1b
(Item 1 less Item 1a)
$
$
2b
(Item 2 less Item 2a)
3b
(Item 3 less Item 3a)
4b
(Item 4 less Item 4a)
5b
(Item 5 less Item 5a)
6b
(Item 6 less Item 6a)
101
Total Interest Refundable
$
102
Total Due Claimant (Add lines 100 and 101 - last column)
REASON FOR CLAIM: (Check reason and explain fully below)
1. Taxes on same property assessed for same year and have been paid more than once.
2. The tax, as a matter of law, was illegal.
3. There was a mathematical error in the computation of the assessment upon which the tax was based, or in the computation of
the tax.
4. Invalid Tax Sale.
Explanation of basis for claim:
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
I hereby certify that the foregoing account is just and correct, that the amount claimed is legally due, after
allowing all just credits, and that no part of the same has been paid.
Claimant_____________________________________
Date of claim ________________________, 20___
Address____________________________________
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