CITY        OF  NEW       ORLEANS

                           DEPARTMENT             Of  FINANCE             I BUREAU     OF   REVENUE

                                                                CLAIM

                                (TO BE FILED WITH THE OFFICE WHERE Cl’tARGE WAS MADE OR TAX      PAID)

o    Refund  of Taxes Illegally. Erroneously, or Excessively    Collected

o Refund     of Amount     Paid For

o Cancellation of     Charge    For

                                             Please Type    or  Print Plainly
Name of Claimant

Number and Street                                               :ity and State

Office to which Payment or Charge Made                          Name      and Mdressof Tax Bill, License or Return if different from above

Period                                                          Kind of Tax or Charge
From                               To
Amount of Ta or Charge              Dates of Payment            Amount to be      Reftinded      Amount     to be Cancelled
S                                                               $                                $
The claimant believes that this claim should be allowed for the following reasons:

                                                Use Revene  Side IF Space S lusnifickat

                                   any accompanying *d*edulós and statement4      bas been  wnilned

                                   SIGNED

                                                                FOR OFFICE USE ONLY
Recommendation    of  office    making charge   or collection:

Payment Reference                                                                 Signed
Date                                                                              Title
APPROVED:                                                       DISAPPROVED:

       Director of Finance                      Chief Administrative Officer                                       City Attorney