CLAIM FOR TAX REFUND
THE STATE OF OHIO, LAKE COUNTY, AFFIDAVIT NUMBER 1
_______________________________________ residing at _____________________________ ________________(zip)_________, Ohio, being first duly sworn upon oath says, that_________ has paid taxes to the County Treasurer of Lake County, Ohio, on the premises hereinafter described in the sum of $______________; That the same was double/over paid by mistake and that ________________________ is the lawful owner of, and is entitled to, a refund of the same. That said payment was for the first/last half of the year _______ for real property situated in the taxing district of ___________________________ as shown in permanent parcel number ______________________________, original lot _______, sublot ________, No. Of acres ____. SECOND: That said taxes were in fact paid by ______________________ and were also paid by ____________________________ without the knowledge that the same had heretofore been paid. THIRD: That the person in whose name said taxes are charged (if other than the claimant) has no interest or right to a refund of the aforesaid taxes and assessments. In case it should be hereafter judicially determined that such taxes and assessments should have been otherwise refunded than to ________________________________ then undersigned agrees in
(Name of who the check is to be payable)
consideration of this refunder to (him)(her)(it), to indemnify JOHN S. CROCKER against any loss or damage by reason of such refunder. __________________________________________ Sworn to before me and subscribed in my presence, this _____ day of _____________, 20____. _________________________________________ NOTARY PUBLIC ___________________________________________________________________________
(Where claimant is a corporation, affidavit number one and affidavit number two should be executed)
THE STATE OF OHIO, LAKE COUNTY,
AFFIDAVIT NUMBER 2
On the ___________ day of ________________, 20____, personally appeared before me, _______________________________who being first duly sworn according to law, says that he/she is duly appointed, qualified and acting ________________of _______________________ a corporation organized and existing under and by virtue of the laws of the Sate of Ohio; that as such officer he/she is duly authorized to make the above affidavit and that the facts and allegations contained therein are true as he/she verily believes. _______________________________________ Sworn to before me and subscribed in my presence this _____ day of _____________, 20_____. _______________________________________ NOTARY PUBLIC
TREAS. FORM E