Form

SECTION A: Requestor

Name *

Address *

Address 2

City *

State *

ZIP Code *

Home # *

Work #

Cell #

Email *

SUBMIT WITH THIS FORM: Proof of payment (maximum of 3), consisting of front and back copies of canceled check(s) or a payment receipt from Sussex County Government. Approved refunds are issued within 30 days after the completed form and all documents are received and processed.

Proof of payment document *

Allowed file types: pdf doc docx.

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Proof of payment document

Allowed file types: pdf doc docx.

View File

Proof of payment document

Allowed file types: pdf doc docx.

View File

SECTION B: Refund Information (Account Information)

Bill Number *

Account Information (Parcel ID or Sewer Account Number)*

Name on Account *

Refund Amount *

SECTION C: If refund is for Requestor, skip this section

Recipient or Organization Name

Address

City

State

ZIP Code