Revised 10/14

To Apply For A Tax Refund, The Taxpayer Must Complete The Following:

Step 1: Property Owner’s

Name and Address

Property

Owner(s) Name:

Account

Number:

Present Mailing Address (Number and Street)

City, Town or Post Office, State, Zip Code Phone (Area Code and Number)

City, Town or Post Office, State, Zip Code Phone (Area Code and Number)

Step 3: Describe The

Property

Legal Description (or attach copy of the tax bill or tax receipt):

Address or location of property:

Step 4: Give the tax

payment information

(*Supporting Payment

Documentation

Check #:

Amount of Refund

Applying For:

Taxpayer’s Reason for Refund (attach supporting payment documentation)

(*):

Step 5: Sign the form

“I hereby apply for the refund of the above-described taxes and certify that the information I have given on this form is true and

correct.”

Sign Here?

Applicant Signature Date of Application for Tax Refund

Determination

(For Office Use Only)

The tax refund is Approved Disapproved

Refund Check #:

Refund Check

Amount:

Sign Here?

Deputy Submitting Refund Application For Approval Date:

Sign Here?

Accounting Manager or Supervisor Approving Payment Date:

Before me, ______________________________________________, on this day personally appeared __________________________________, known to me or proved

to

me to be the person whose name is subscribed to the foregoing instrument and acknowledged to me that he/she executed the same for the purposes and

consideration

therein expressed. I do hereby affirm that I am the taxpayer (or taxpayer representative) for property tax account # __________________________. A check in the

amount

of $______________ was issued to Tammy J. McRae - Montgomery County Tax Assessor/Collector with the intent to be credited to account number(s)

________________________________. I do hereby request a refund of above amount. I do not have the original tax receipt for the taxes paid. I hereby agree

to