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AFFIDAVIT

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					                                               AFFIDAVIT

I the undersigned, an owner or other authorized agent of _________________________
__________________________ (name of settlement company) do hereby certify that I have reviewed the
list of documents and amounts collected, provided by the Loudoun Circuit Court Clerk’s Office, which
were assessed the Congestion Relief Fee, commonly referred to as the local grantor’s tax. I further certify
that I am the settlement agent as defined in Section 6.1-2.10 of the Code of Virginia and authorized
pursuant to HB 1578 (Chapter 652 of the Acts of Assembly, 2008) to receive the refund of the Congestion
Relief Fee, on behalf of the parties who paid the Congestion Relief Fee.

I do further certify that:

         _____     My records concur with the documents and amounts collected, as reflected
                   in the list provided by the Clerk’s office.

         _____     I certify the attached list identifying the deed instrument number and RCR fee are correct.




Date: ____________________                                      _____________________________
                                                                Signature:
                                                                _____________________________
                                                                Name Printed:
                                                                _____________________________
                                                                Title:
                                                                ______________________________
                                                                Email Address
                                                                ______________________________
                                                                Phone Number

Commonwealth of Virginia:
City/County of _________________:

  The foregoing Affidavit was subscribed and sworn before me this ______ day of __________, 2008, by
_______________________________________________________ (person acknowledging) on behalf of
______________________________________________(name of company or entity).

                                                                ______________________________
                                                                Notary Public

Notary Registration Number: __________________
My Commission Expires:      __________________


Please make the refund check in the amount of $: ______________________________________________

Payable to: ____________________________________________________________________________

and mail to:____________________________________________________________________________

_____________________________________________________________________________________.
Please enter Instrument Number and RCR Fee for each deed you are requesting a refund.

      Instrument Number                        RCR Fee
  1
  2
  3
  4
  5
  6
  7
  8
  9
 10
 11
 12
 13
 14
 15
 16
 17
 18
 19
 20
 21
 22
 23
 24
 25
 26
 27
     Instrument Number   RCR Fee
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
     Instrument Number   RCR Fee
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83

				
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