tiy tt ff - New York City

1 IMPORTANT: ATTACH COPIES OF ALL CANCELLED CHECKS/ MONEY ORDERS/ RECEIPTS showin g the payments made whic h are to be tra nsferred or re funded. RETURN COMPLETED APPLICATION TO: Depart ment of Enviro nmental Protection Bure au of Customer Serv ic es REFUND DEPARTMENT 59-17 JUNCTION BLVD., 7t h Floor FLUSHING, . 11373 INSTRUCTIONS FOR COMPLETING THIS REFUND APPLICATION Number: Enter the 13 digit billing account number. Block Lot: Enter the boro ugh, blo ck, and lot number of the pro pert y. Address: Enter the street address of the pro pert y. / Owner s Name: Enter the name of the person or entit y that owns the pro pert y.

2 If the applicant applyin g for refund is NOT the owner, ple ase indicate the pro pert y owner s name AND submit a notarized letter signed by the owner. Address: Enter the mailing addre ss of the pro pert y if it is different than the Serv ic e Address. If the two addresses are the same, enter SAME . Property Purchas ed: Enter the date the pro pert y was acquired. Phone Number: Enter your home and/or busin ess phone number, or mobile phone number where you can be re ached during normal busin ess hours (9 am - 5 pm). or Transfer: Indicate whether you wis h to receive a refund check or have the credit transferred to another DEP pro pert y account.

3 Ple ase specify the dollar amount. If Transfer: Indicate the 13 dig it account number where the cre dit should be tra nsferred to. If Refund: Indicate the name and address where the re fund check should be mail ed. Escrow Account: Ple ase check the appro priate box. YES, gi ve the name and addre ss of bank or mort gage company. antee: Read the agreement, enter name, the account number, and the serv ice address. Print signer s name, then sign and date the form. NOTE: ALL CREDIT BALANCES ARE SUBJECT TO VERIFICATION. YOU MUST ATTACH COPIES OF CANCELL ED 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.

4 IF YOU DO NOT PROVI DE PROOF OF PAYMENT(S ), YOUR REFUND MAY NOT BE PROCESSED. FOR OFFICE ONLY Tra ckin g No. _____ Date Received: _____ NEW york city DEPARTMENT OF ENVIRONMENTAL PROTECTION BUREAU OF CUSTOMER SERVICES - REFUND DEPARTMENT REFUND & TRANSFER OF CREDIT APPLICATION No. (found on water bill) : BLOCK: LOT: Address:(Include city , State, Zip Code) / Owner s Name:IF YOU ARE NOT THE OWNER OF THE PROPERTY, YOU MUST SUBMIT A NOTARIZED LETTER OFAUTHORIZATION FROM THE OWNER AND ATTACH IT TO THIS Address:(If same as Service Address, write Same ) Property 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 NAME: ADDRESS: your payments made through a mortgage escrow account?

5 Yes No yes, provide the name of the bank or mortgage company and their address:Name: Address: 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 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 SIGNATUREFOR OFFICE USE ONLY: Application Processed by: _____ Date: _____ Application Reviewed by: _____ Date: _____ Approved by: _____ Date: _ _____ Approved by: _____ Date: _ _____ IF REFUND: MAIL REFUND CHECK TO: INFORMATION.