Planning & Development
1400 North Boulevard Tampa, FL 33607
(813) 274-3100 * Fax (813) 259-1712
REFUND
REV 01/23/20
PRIVATE PROVIDER APPLICATION FOR REFUND
REQUEST FOR REFUND
CONTACT INFORMATION
Private Provider Firm: ____________________________________________________________
Payor Name: _________________________________ Phone: ___________________________
Email:_________________________________________________________________________
Payor Mailing Address:___________________________________________________________
Payment Type: Check (please submit copy of cancelled check with refund form)
Credit Card Last four digits: _________ Expiration Date: ___________
**Refund will be issued to Payor**
PROJECT INFORMATION
City of Tampa Permit No.: ______________________________________________________________
Project Address: ________________________________________________________________
Service Provided: Plan Review Inspections
Office Use Only
Approved for refund? Yes Amount: No
If not approved, reason: __________________________________________________________
____________________________ ______________________________
Reviewed by (Printed Name) Reviewed by (Signature)
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