REQUEST FOR REFUND

Refund requests shall be submitted by completing the following form. Other informal requests cannot be processed.

Permit Number

Permitted Address

Company or person permit was issued to:

A refund is being requested for the following reason. Please be specific.

Refund Amount Requested

Has the company or person applying for this refund filed for bankruptcy protection that could affect this refund request?

Please confirm that a copy of the petition filed with the United States Bankruptcy Court will be attached to this request.

Yes

Select the appropriate filing type

Case Number

Provide the Name, Address and Phone number of the trustee where a trustee has been assigned or include a statement that you or your company is acting as debtor in possession and that no challenges have been made to that status.

Upload any relevant documentation.

Click Here to Upload

The refund will be issued to the party that is listed on the original receipts. Any exceptions will require a letter from the original receipt recipient, authorizing the Town of Gilbert to release payment to a third party.

Remit check to:

Phone Number for individual completing the refund request.

Email address for individual completing the refund request.

Sign Here

First Name

Last Name

Choose how to sign

Draw Type

I agree to electronically sign and to create a legally binding contract between the other party and myself, or the entity I am authorized to represent.