EXHIBIT B
REFUND CLAIM
(SAMPLE)
CLAIM ON THE TREASURY OF THE
COUNTY OF SANTA BARBARA, STATE OF CALIFORNIA
Department: 0410 Auditor/Controller
Claimant Name: University of California
2200 University Avenue
Mailing Address: Berkeley, California 94720
Attention: University Controller
For the sum of $ 974.40, Being For Refund on Leased Equipment R/T 202.2 and 5096
Date Items Amount
10/79 As provided by sections 202.2 and 5096 of the Revenue and Taxation
Codes, refund due to exemption of certain leased properties to
public entities executed prior to Sept. 20, 1978. Attach copy of
agreement.
Parcel # 0 000 00 851
TRA 66 011
Bill # 14136 79/80 974.40
The undersigned, under penalty of perjury, states: That the above claim and the items are therein set out are true correct, that no part
thereof has been heretofore paid; that the amount therein is justly due; and that the same is presented not later than one year after the accrual
of the cause of action.
DON'T sign firm name - sign YOUR name here.
X x
CLAIMANT SIGNATURE (Date of Signature)
BELOW FOR COUNTY USE ONLY
Expenditure Authorized and Approved By:_____________________________________________________________________
AUTHORIZED DEPARTMENTAL SIGNATURE
Department No. Claim No. Signature Date Contract No. P/F Fund No.
0410 7-15 013 008 014 0170
000 194611
Issue Date Vendor No. Descriptive Purpose of Claim - Limit to 30 Spaces
009 023 01.1 Refund on 79/80 Unsec. Leased Equipment
If as stated, above is a LEGAL CHARGE, against Account No. Amount PY Division Project Activity Facility
the County for the sum of $ 102 & 974.40 &
102 & & & & &
102 & & & & &
Computations certified correct 102 & & & & & I&
102 & & & & &
KRISTI M. JOHNSON 102 & & & & &
Auditor-Controller 102 & & & & &
By_____________________ 102 & & & & &
Deputy Auditor
AC-120 Rev. 1/79 Date______ TOTAL 006 974.40