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APPLICATION FOR REFUND

Parcel No.

Parcel No.

The above referenced parcels have been improperly and illegally assessed. The accurate
information is as follows:

Parcel No. (No such building exists)

Parcel No. 4,011 (Not 4,035)

Pursuant to O.C.G.A. § 48-5-241, the undersigned Taxpayer is entitled to a refund for three (3)
years of taxes (2010, 2009 and 2008) and for such other and further relief as may be equitable,
appropriate and just.

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