Fillable County of San Bernardino Clerk of the Board (San Bernardino County Assessor-Recorder-Clerk)

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County of San Bernardino Clerk of the Board (San Bernardino County Assessor-Recorder-Clerk)

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County of San Bernardino
Clerk of the Board of Supervisors
385 N. Arrowhead Avenue, 2
nd
Floor, San Bernardino, CA 92415-0130
(909) 387-3841 Fax (909) 387-4554
Internet: www.sbcounty.gov
cob011/claimrefundtaxpayment Revised 3/20/2013
CLAIM FOR REFUND OF TAX PAYMENT(S)
Claimant’s Name:
First:
Last:
Mailing Address:
City:
State:
Zip:
Contact No.:
( ) -
Assessor’s Parcel Number:
(Parcel # is 13 digits)
Property Address:
City:
Zip:
In accordance with the provisions of Chapter 5, Article I, of the California Revenue and Taxation Code
(commencing with Section 5096), I am (we are) herewith filing this claim with the Board of Supervisors of the
County of San Bernardino, and ask that a refund of taxes and/or penalties be made for the following amounts:
Fiscal Year(s)
Refund is Claimed
Date(s) Taxes Paid
Amount of Tax Claim
Amount of Penalty
Claim
Total Amount
20___
$
$
$
20___
$
$
$
20___
$
$
$
20___
$
$
$
20___
$
$
$
I (we) claim that the whole assessment (part of the assessment) for the year(s) as shown above is (are) void
for the following reasons (use attachments if necessary):
I hereby declare under penalty of perjury under the laws of the State of California that the foregoing is true and
correct; that the taxes and/or penalties sought to be refunded were paid within four years prior to the filing of
this claim; that the amounts herein claimed are correct; and no part thereof has been refunded to the claimant
or to any other person on claimant’s benefit; and if acting on behalf of a legal entity, I am duly authorized to act
on its behalf and that the title shown below is true and correct.
Date:
Signature:
Title:
PLEASE NOTE: This form is provided as a courtesy and does not constitute legal advice to claimants. Claimants are
strongly advised to consult an attorney regarding their rights and obligations, particularly with regard to exhaustion of
administrative remedies and the applicability of statutes of limitation on filing claims and lawsuits for refund of property taxes.
THIS FORM MUST BE SIGNED AND RETURNED WITH PROOF OF TAX PAYMENT TO: San Bernardino County,
Clerk of the Board of Supervisors, 385 North Arrowhead, 2
nd
Floor, San Bernardino, CA 92415-0130.
County Use Only
Clerk of the Board (909) 387-3841
Date Received:
Date Referred to County Counsel:
Signature:
Title:
Date:
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County of San Bernardino Clerk of the Board (San Bernardino County Assessor-Recorder-Clerk)

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Completed 31 January 2021

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