Redemption Request

Submitters FIRST and LAST Name*

Submitters Email*

Lot*

Block*

Qualifier

Property Owner*

Property Location*

Redeeming Party* PLEASE PROVIDE ADDRESS WHERE CERTIFICATES ARE TO BE MAILED

PROOF OF LEGAL INTEREST REQUIRED. HOMEOWNER MAY BE REQUIRED TO SUBMIT A COPY OF DRIVER’S LICENSE.

Person Requesting Redemption *

Company (if not owner.)*

Enter N/A if the owner is requesting.

Phone Number *

Fax Number

Date Payment Will Be Received in Our Office *

PLEASE CHOOSE YOUR PAYMENT DATE CAREFULLY AS THIS IS THE DATE THAT PAYMENT MUST BE RECEIVED IN OUR OFFICE. IF RECEIVED BEFORE OR AFTER THE DATE REQUESTED, FUNDS WILL BE RETURNED.

Message from Submitter (if any)