CHWP Refund Request Form

Claremont Hills Wilderness Park Parking Meter Refund Request
INSTRUCTIONS: Please complete the form below and provide as much information as possible to expedite your request. Incomplete or unverified requests may be denied. You will be notified via email of your refund's approval status. For further questions, please contact the Recreation and Human Services Department at (909) 399-5331.
Name

First NameLast Name
Mailing Address

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Date of Transaction(s)

MonthDayYear
Date
Refund Amount Requested
Approximate Time of Transaction(s)

Hour Minutes

AM/PM Option
Last 4 Digits of Credit Card Utilized
If more than 1 card was used, separate with commas.
Vehicle License Plate Number
Leave special characters blank
Please list the reason for your request:
Please upload ALL copies of your receipts, credit card transaction history that verifies the multiple charges, and any other information that support your request.

Cancelof
NOTE: Refunds are subject to review and approval. Upon approval, refunds will be paid by check to the address provided above in accordance with the City's accounts payable schedule. The review and payment process may take up to four (4) weeks.

ACKNOWLEDGEMENT

By signing this form, I declare that the information I have provided on this application is true and correct under CaliforniaPenal Code 115. (a) “Every person who knowingly procures or offers any false or forged instrument to be filed,registered, or recorded in any public office within this state, which instrument, if genuine, might be filed, registered,or recorded under any law of this state or of the United States, is guilty of a felony.”
Signature
Date

MonthDayYear
Date
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Claremont Hills Wilderness Park Parking Meter Refund Request