Input N/A if the payer was your mortgage company.
This file should display your name, City of Coquitlam as the payee, the dollar amount and date of the payment made in error, and the account number that the payment was made to.
By ticking the agree box below I confirm that the information provided in this Refund Request is true and correct to the best of my knowledge. I hereby authorize a refund to be issued using the information provided in this form. By ticking the agree box below I also acknowledge and accept the $25 refund processing fee that will be deducted from the refund balance.
I understand by submitting this form I am consenting to the collection, storage, use and disclosure of my personal information for the purposes of the Refund Process in accordance with the Freedom of Information and Protection of Privacy Act. I understand that my personal information will be disclosed to a third-party service provider (i.e. website host Civic Plus, MicroSoft) located in Canada for the purpose of processing my request. If you have questions or concerns about the collection of your personal information please contact Revenue Services at 604-927-3050 or email Revenue Services.
This field is not part of the form submission.
* indicates a required field