Please be advised the information below is needed in order for our office to refund to the bidder. The form must be completed by the UPSET BIDDER AND AGENT WILL NOT BE ALLOWED TO REQUEST A REFUND.

Date of Request:
File Number:
Name and Address of Individual or company in which the bid has been placed:
PRINT NAME of individual Requesting Refund:
Telephone Number of Individual Requesting Refund:
SIGNATURE of lndivid'ual Requesting Refund :
Amount of deposit hele by clerk office:
Note: Clerk May Request Receipts