Annual Report Overpayment

Annual Report Overpayment

Annual Report Overpayment Verified Claim Form

ID#:

Name and Address of Entity:

Name:

Address:

The above entity is requesting a refund in the amount of $ for the ____________ Annual (dollar amount) (year) Report as evidenced by the attached documentation.

The reason for requesting the refund is as follows:

 

Signature: __________________________________

Date: (mm/dd/yyyy)

Print Name:

Title:

 

Form must be notarized.

 

Sidebar