Fillable Refund-Authorization City of Huntington Beach

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Refund-Authorization City of Huntington Beach

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City of Huntington Beach
Community Services Department
2000 Main Street, Huntington Beach, CA 92648-2702
(714) 536-5486
Refund Authorization
FACILITY__________________________ DATE OF EVENT___________________
*If you will pay for your rental with a credit card (Visa, MC, or Discover) enter the
information for that card below. Please present card to clerk for payment. Refunds are
processed 7-10 days after event.
Name on Card _______________________________________________
Credit Card Number __ __ __ __ - __ __ __ __ - __ __ __ __ - __ __ __ __
Expiration Date ___ 3-Digit Code on Back _____________
Signature
MONTH / YEAR
OR
*If you will pay by check or cash, indicate the name and address of where to send the
refund check. Please allow up to 4-6 weeks after the event for processing.
Tell us which name to make the refund check payable to and provide a mailing
address. (Please fill out even if the information is the same on the application)
NAME
NUMBER STREET APT#
CITY STATE ZIP
---------------------------FOR DEPARTMENT USE ONLY-----------------------
Reason for Refund
Security Deposit $
Insurance $
Rental $
$
Total Refund Due $
Submitted by: Date:
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Refund-Authorization City of Huntington Beach

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Completed 13 June 2020

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