Refund Request
29 Bowler Avenue, Gore 9710
PO Box 8, Gore 9740
Phone 03 209 0330
Email info@goredc.govt.nz
www.goredc.govt.nz
Refund Request Form
1
Refund
Rates Dog Registration Debtors Water Other:
Assessment No. Animal No.
Customer No. Other/GL Code:
Reason for Refund:
Refund Amount: $
Method of Refund: Cheque Bank Transfer (Note: GDC only make payments on the 20th of each month)
Account Name:
Account Details:
Bank Branch Account Number Suffix
Name (in full):
Postal Address:
Phone (home/mobile): Email:
Signature: Date:
OFFICE USE ONLY
Completed by:
Date Received: Signature:
Refund Authorised: Yes No
Refund approved Signature: Position: Date:
Payment approved Signature: Position: Date:
RURAL CITY LIVING
Creditor Refund
Creditor (AP) Number:
Bank Account Number given/ Already has a creditor
account setup
GDC Transfer
select one of the below
AP 587.01
(electronic)
AP 14.01
(cheque)
To account:
Internal transfer only
Non Creditor Refund
* No bank Account Number given (Cheque only)
