"Refund and Transfer of Credit Application" - New York City

Refund and Transfer of Credit Application is a legal document that was released by the New York City Department of Environmental Protection - a government authority operating within New York City.

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FOR OFFICE ONLY
Tracking No. _________________________
Date Received: _______________________
IMPORTANT: ATTACH COPIES OF
ALL CANCELLED CHECKS/ MONEY ORDERS/ RECEIPTS
showing the payments
made which are to be transferred or refunded.
RETURN COMPLETED APPLICATION TO:
Department of Environmental Protection
Bureau of Customer Services – REFUND DEPARTMENT
59-17 JUNCTION BLVD., 7th Floor
FLUSHING, N.Y. 11373
INSTRUCTIONS FOR COMPLETING THIS REFUND APPLICATION
1. Account Number: Enter the 13 digit billing account number.
2. Borough – Block – Lot: Enter the borough, block, and lot number of the property.
3. Service Address: Enter the street address of the property.
4. Applicant / Owner’s Name: Enter the name of the person or entity that owns the property. If the
applicant applying for refund is NOT the owner, please indicate the property owner’s name AND submit a
notarized letter signed by the owner.
5. Mailing Address: Enter the mailing address of the property if it is different than the Service Address. If the
two addresses are the same, enter “SAME”.
6. Date Property Purchased: Enter the date the property was acquired.
7. Daytime Phone Number: Enter your home and/or business phone number, or mobile phone number
where you can be reached during normal business hours (9 am - 5 pm).
8. Refund or Transfer: Indicate whether you wish to receive a refund check or have the credit transferred to
another DEP property account. Please specify the dollar amount.
If Transfer: Indicate the 13 digit account number where the credit should be transferred to.
If Refund: Indicate the name and address where the refund check should be mailed.
9. Mortgage Escrow Account: Please check the appropriate box.
10. If YES, give the name and address of bank or mortgage company.
11. Guarantee: Read the agreement, enter name, the account number, and the service address. Print signer’s
name, then sign and date the form.
NOTE: ALL CREDIT BALANCES ARE SUBJECT TO VERIFICATION. YOU MUST ATTACH COPIES OF CANCELLED
CHECKS, MONEY ORDERS OR PAYMENT CONFIRMATION RECEIPTS. THE AMOUNT OF THE CHECKS AND/OR
RECEIPTS SHOULD BE EQUIVALENT TO OR GREATER THAN THE AMOUNT OF THE REFUND YOU ARE REQUESTING.
IF YOU DO NOT PROVIDE PROOF OF PAYMENT(S), YOUR REFUND MAY NOT BE PROCESSED.
FOR OFFICE ONLY
Tracking No. _________________________
Date Received: _______________________
IMPORTANT: ATTACH COPIES OF
ALL CANCELLED CHECKS/ MONEY ORDERS/ RECEIPTS
showing the payments
made which are to be transferred or refunded.
RETURN COMPLETED APPLICATION TO:
Department of Environmental Protection
Bureau of Customer Services – REFUND DEPARTMENT
59-17 JUNCTION BLVD., 7th Floor
FLUSHING, N.Y. 11373
INSTRUCTIONS FOR COMPLETING THIS REFUND APPLICATION
1. Account Number: Enter the 13 digit billing account number.
2. Borough – Block – Lot: Enter the borough, block, and lot number of the property.
3. Service Address: Enter the street address of the property.
4. Applicant / Owner’s Name: Enter the name of the person or entity that owns the property. If the
applicant applying for refund is NOT the owner, please indicate the property owner’s name AND submit a
notarized letter signed by the owner.
5. Mailing Address: Enter the mailing address of the property if it is different than the Service Address. If the
two addresses are the same, enter “SAME”.
6. Date Property Purchased: Enter the date the property was acquired.
7. Daytime Phone Number: Enter your home and/or business phone number, or mobile phone number
where you can be reached during normal business hours (9 am - 5 pm).
8. Refund or Transfer: Indicate whether you wish to receive a refund check or have the credit transferred to
another DEP property account. Please specify the dollar amount.
If Transfer: Indicate the 13 digit account number where the credit should be transferred to.
If Refund: Indicate the name and address where the refund check should be mailed.
9. Mortgage Escrow Account: Please check the appropriate box.
10. If YES, give the name and address of bank or mortgage company.
11. Guarantee: Read the agreement, enter name, the account number, and the service address. Print signer’s
name, then sign and date the form.
NOTE: ALL CREDIT BALANCES ARE SUBJECT TO VERIFICATION. YOU MUST ATTACH COPIES OF CANCELLED
CHECKS, MONEY ORDERS OR PAYMENT CONFIRMATION RECEIPTS. THE AMOUNT OF THE CHECKS AND/OR
RECEIPTS SHOULD BE EQUIVALENT TO OR GREATER THAN THE AMOUNT OF THE REFUND YOU ARE REQUESTING.
IF YOU DO NOT PROVIDE PROOF OF PAYMENT(S), YOUR REFUND MAY NOT BE PROCESSED.
NEW YORK CITY DEPARTMENT OF ENVIRONMENTAL PROTECTION
BUREAU OF CUSTOMER SERVICES - REFUND DEPARTMENT
REFUND & TRANSFER OF CREDIT APPLICATION
ACCOUNT INFORMATION:
1. Account No. (found on water bill):
2. BOROUGH:
BLOCK:
LOT:
3. Service Address:
(Include City, State, Zip Code)
4. Applicant / Owner’s Name:
IF YOU ARE NOT THE OWNER OF THE PROPERTY,
YOU MUST SUBMIT A NOTARIZED LETTER OF
AUTHORIZATION FROM THE OWNER
AND ATTACH IT TO THIS FORM.
5. Mailing Address:
(If same as Service Address, write “Same”)
6. Date Property Purchased:
7. Daytime Phone Number:
8. Do you wish to receive a refund or to transfer the credit to another water and sewer account:
REFUND
Specify Amount
$
CREDIT TRANSFER
Specify Amount
$
IF TRANSFER, INDICATE THE ACCOUNT NUMBER THE CREDIT IS TO BE TRANSFERRED TO:
NOTE: NEW CHARGES BILLED TO THE ACCOUNT WILL BE DEDUCTED FROM ANY CREDIT BALANCE
IF REFUND: MAIL REFUND CHECK TO:
NAME:
ADDRESS:
9. Were your payments made through a mortgage escrow account?
Yes
No
10. If yes, provide the name of the bank or mortgage company and their address:
Name:
Address:
11. GUARANTEE
PAYEE AGREES TO HOLD THE CITY HARMLESS AND GUARANTEES THAT IN THE EVENT THAT ANY OTHER
PARTY SUCCESSFULLY PROVES THAT THIS CREDIT WAS DUE TO THAT PARTY, PAYEE WILL INDEMNIFY THE
WATER BOARD FOR ANY ADDITIONAL FUNDS THAT ARE REQUIRED TO BE DISBURSED.
I,
, (applicant name), have overpaid water/sewer charges and am
#
entitled to the refund and/or credit from the N.Y.C. Water Board for Account
located at:
(Service Address)
Print Name:
(PLEASE PRINT FULL NAME HERE)
Sign Name:
Date of Application:
(Month/Day/Year)
*NO REFUNDS WILL BE ISSUED WITHOUT AN ORIGINIAL SIGNATURE
FOR OFFICE USE ONLY:
Application Processed by: _________________________ Date: ______________________
Application Reviewed by: _________________________ Date: ______________________
Approved by:
_________________________ Date: ______________________
Approved by:
_________________________ Date: ______________________
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