SEE INSTRUCTION ON REVERSE SIDE LOS ANGELES COUNTY AUDITOR-CONTROLLER PROPERTY TAX SERVICES DIVISION REQUEST FOR REISSUANCE OF POST OFFICE RETURNED REFUND JOHN NAIMO AUDITOR-CONTROLLER TO: AUDITOR-CONTROLLER PROPERTY TAX SERVICES DIVISION 500 WEST TEMPLE STREET, ROOM 153 LOS ANGELES, CA 90012 (213) 974-8368 (1) (2) DATE ______________________ ASSESSOR ID NUMBER or UNSECURED BILL NUMBER ___________________________________________ YEAR /SEQUENCE ____________________ TAX AGENT REGISTRATION NUMBER ____________________ (3) NEW ADDRESS _________________________________________________________________________ MAILING ADDRESS _________________________________________________________________________ _________________________________________________________________________ (4) (5) (6) *REQUESTED BY _________________________________________________________________________ TELEPHONE NUMBER ___________________________________ **TYPE OF IDENTIFICATION ___________________________________________________________ I certify, under penalty of perjury, that I am the rightful claimant to this property tax refund warrant, or acting with authority on behalf of the rightful claimant, which represents a refund of property taxes previously paid by me, or the rightful claimant, to whom I represent. (7) SIGNATURE(S) OF CLAIMANT(S) or AUTHORIZED REPRESENTATIVE ____________________________________________ * ** ____________________________________________ If requested by tax agent, a completed authorization of tax agent and agent registration number is required. A photocopy of identification(s) must be attached. Acceptable identification include: driver's license; state identification card; U.S. passport or U.S. military identification. RE-ISSUANCE OF REFUND WARRANTS WILL NOT BE ISSUED WITHOUT A SIGNATURE AND PROPER IDENTIFICATION LISTED ABOVE BY CLAIMANT OR AUTHORIZED AGENT. "To Enrich Lives Through Effective and Caring Service" American LegalNet, Inc. www.FormsWorkFlow.com INSTRUCTION FOR FILING OUT RE-ISSUANCE OF REFUND WARRANT FORM This form is to be used to request a cancelled warrant that has been returned by the United States Post Service be reissued. (1) (2) Date of Request. The Assessor Identification Number (AIN) or Unsecured Bill Number and the Years and Sequences in question. Tax Agents Registration Number (if application is signed by tax agent). (3) (4) The new address to be used either to issue replacement warrant. Signature(s) of authorized person(s) requesting the change of address. Payee(s) authorized tax agents or authorized representatives of a company. If multiple payee(s) listed, all must sign. Phone number of the authorized person(s) requesting the change of address. Identify acceptable identification and attain a photocopy of all authorized person(s) requesting re-issuance of refund warrant (requests submitted by mail included). All taxpayer(s) or authorized agent signature in INK. Note: If the refund warrant amount is $5,000.00 or more, PROOF of PAYMENT verification for relevant tax year(s) is required. Incomplete information submitted will result in a delay of processing and re-issuance of refund. (5) (6) (7) "To Enrich Lives Through Effective and Caring Service" American LegalNet, Inc. www.FormsWorkFlow.com