Chicago City Council - Committee on Finance - Application for Senior Citizens Sewer C... Page 1 of 1
City of Chicago Claim Form
Application For Senior Citizens Sewer Charge Annual Refund
Fill in the fields below and print form. Sign and take this to your alderman's office.
FOR OFFICIAL USE ONLY
CLAIM*_
WARD_
DATE_
STATUS_
R_
11
Claimant Name
Claimant Address
Claimant
City, State & Zip Code
Claimant Telephone
Claimant Birthdate:
Property Tax Number:
Water Account Number:
Building Type:
Note: *AII Fields Must Be Filled In
Polly V Dixon
1460 North Sandburg Terrace, Unit 406
Chicago, IL 60610
Office
312 642 0318
Home
312 642 0318
Cellular
13/06/1933
PIN 17- 04- 207- 086- 1136
585267-585267
Condo
Com Units
Res Units
i. Vb\\M v- vX^crvA_ _(print your name), the undersigned on
oath deposes and states that I am the applicant on this application, that I am the owner of record of said real estate property or that I have a legal or equitable interest therein, that I am 65 years of age or older, and otherwise qualify for a refund under Section 3-12-050 of the Municipal Code of the City of Chicago, that all water taxes, property taxes, and all other fees, penalties or assessments owed to the City of Chicago have been paid and that I understand I am subject to penalties for perjury or falsification herein.
DATE: /ao/aoVOWNER SIGNATURE:;
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Print this claim form
Please print this and return application to your aldermanic office before July 1
) 2007 Chicago City Council - Committee on Finanace. All Rights Reserved
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1/20/2011
City of Chicago
Department of Revenue-Water Division
P.O. Box 6330
Chicago, Illinois 60680-6330
Customer Service: 312-744-4426 E-mail: waterbill@cityofchicago.org
Always include your name, account number, and a call back number. Web: www.cityofchicago.org/revenue
METERED ACCOUNT
Little leaks cause big bill...
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