PRESCRIBED BY STATE BOARD OF ACCOUNTS
COUNTY FORM NO. 17T (REV. 2014)
APPROVED BY DEPARTMENT OF LOCAL GOVERNMENT FINANCE
County, Indiana
ON ACCOUNT OF TAX REFUND
Taxing Unit
______________________________
DESCRIPTION OF PROPERTY
AMOUNTS PAID
LESS
PAID BY TAXPAYER
HOMESTEAD
STMT.
LESS PROP.
CREDIT
PROC.
DUE DATE
TAX REPL.
AND/OR
LESS:
CHRG.
ITEM
OF INSTALL-
DUPLICATE
CREDIT
RES
CIRCUIT
PENALTIES
NO.
DATE PAID
MENT
NO.
GROSS TAX
(PTRC)
PTRC
BREAKER
NET TAX
& INTEREST TOTAL PAID
1
$
$
$
$
$
$
$
2
3
4
5
6
(1)
AMOUNTS PAYABLE
LESS
AMOUNT DUE FROM TAXPAYER
HOMESTEAD
STMT.
LESS PROP.
CREDIT
PROC.
TAX REPL.
AND/OR
LESS:
CHRG.
ITEM
CREDIT
RES
CIRCUIT
NET TAX
PENALTIES
NO.
GROSS TAX
(PTRC)
PTRC
BREAKER
DUE
& INTEREST
TOTAL DUE
1a
$
$
$
$
$
$
$
2a
3a
4a
5a
6a
(1)
(1) 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)
ITEM NO.
1b
2b
3b
4b
5b
6b
TOTAL
Overpayment Amount (Total Paid - Total Due)
$
$
$
$
$
$
$
Year ________
Rate ________
Days
Year ________
Interest
$
$
Year ________
Rate ________
Days
Year ________
Interest
$
$
$
$
Year ________
Rate ________
Days
Year ________
Interest
$
$
$
$
$
$
Total Interest
$
$
$
$
$
$
$
Total Refund or Credit
$
REASON FOR REFUND: (Check reason and fully explain)
1.
Taxes on same property assessed for same year and have been paid more than once - Process claim in accordance IC 6-1.1-26-1
and use the DOR certified rate of interest.
2.
The tax as a matter of law was illegal - Process claim in accordance with IC 6-1.1-26-1 and use the DOR certified rate of interest.
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 -
Process claim in accordance with IC 6-1.1-26-1 and use the DOR certified rate of interest.
4.
Refund/credit as provided under IC 6-1.1-15 (not subject to IC 6-1.1-26-1). Use DOR certified rate of interest per IC 6-1.1-37-11.
5.
Invalid Tax Sale - Process per court order and pay 5% interest per IC 6-1.1-25-10.
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