Full Payment Certificate Application Form - City Of Chicago Department Of Finance
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1
2CERTIFICATE #:
DATE:
A.K.A
FULL PAYMENT CERTIFICATE APPLICATION
City of Chicago Department of Finance
333 South State Street- Suite 330
BOOK
Page
MC#(s)
Phone: (312) 744-4426
Monday-Friday 8:30 AM – 4:30 PM
APPLICATIONS ARE REQUIRED FOR ALL TRANSFERS OF PROPERTY. SEPARATE APPLICATIONS ARE REQUIRED FOR EACH PROPERTY TO BE TRANSFERRED.
FPC Fee $50 per account. The FPC fee is waived if the subject property is exempt from the City of Chicago Real Property Transfer Tax. APPLICATION # ______ OF ______ (Qty)
1.
PREMISES INFORMATION
PREMISES ADDRESS(ES): __________________________________________________________________________________________________________________________________________________________________________________
PROPERTY INDEX # (S): __________________________________________________________________________________ WATER ACCOUNT # (S): __________________________________________________________________________
o
o
o
o
CHECK ALL APPLICABLE:
SINGLE FAMILY HOME
CONDO/TOWNHOUSE/CO-OP (INDIVIDUALLY BILLED)
CONDO/TOWNHOUSE/CO-OP (ASSOCIATION BILLED)
CONDO CONVERSION
o
o
o
o
o
o
o
o
APT BLDG < 6 UNITS # of units ____
APT BLDG ≥ 6 UNITS # of units ____
MIXED USE
COMMERCIAL
INDUSTRIAL
NEW CONSTRUCTION
RAILROAD
REFINANCE ONLY
o
VACANT LOT
o
CORNER PROPERTY
o
MULTIPLE PINs
o
FORECLOSURE
o
TAX SALE
o
RECEIVERSHIP
o
TRANSFER TAX EXEMPT Exemption #_________________
o
OTHER Describe______________________________________
3.
SCHEDULED METER READING
2.
SUPPORTING DOCUMENTATION REQUIRED
SUPPLY INFORMATION FOR A LOCAL
(CHECK TO CONFIRM THE ATTACHMENT OF SUPPORTING DOCUMENTS REQUIRED FOR PROCESSING.)
CONTACT PERSON WHO IS ABLE TO
DOCUMENT
REQUIRED FOR
PROVIDE ACCESS TO THE PROPERTY
o
LEGAL DESCRIPTION
- COMMERCIAL, MIXED USE, CORNER PROPERTY, CONDO CONVERSION, MULTIPLE PINs, APT BLDG ≥ 6 UNITS
FROM 7 AM - 3:30 PM, MON - FRI.
o
PLAT OF SURVEY
- NEW CONSTRUCTION, INDUSTRIAL, VACANT LAND, RAILROAD, OTHER
NAME: _________________________________
o
COURT ORDER/DEED
- FORECLOSURE, TAX SALE, RECEIVERSHIP
PHONE: ________________________________
4.
BUYER INFORMATION
NAME: ___________________________________________________________________ EMAIL: ____________________________________________________________________________ PHONE: __________________________________
BUYER REQUESTS FUTURE BILL BE MAILED TO:
NAME: __________________________________________________________________________________ ADDRESS: _____________________________________________________________________________________________________
5.
SELLER INFORMATION
NAME: ___________________________________________________________________ EMAIL: ____________________________________________________________________________ PHONE: __________________________________
6.
PREPARER INFORMATION
NAME/COMPANY: __________________________________________________________ EMAIL: ____________________________________________________________________________ PHONE: __________________________________
______________________________________________________________________________________
____________________________________________________________________________________________________
PRINT NAME
SIGNATURE (CIRCLE ONE) S E L L E R / B U Y E R / A T T O R N E Y / A G E N T
Water Acct#: __________________________________________
Water Charge $ ______________
FPC Charge $: ______________
Water Acct#: __________________________________________
Water Charge $ ______________
FPC Charge $: ______________
Water Acct#: __________________________________________
Water Charge $ ______________
FPC Charge $: ______________
Based Upon
o FINAL METER READING TAKEN ____/____/______
o NON-METERED ____/____/______
1. CLOSING BASED UPON A FINAL METER READING MUST OCCUR WITHIN 60 DAYS OF EITHER: (A) THE FINAL READING DATE, OR (B) THE AUTHORIZATION DATE, WHICHEVER IS EARLIER
2. CLOSING BASED UPON A NON-METERED TERM MUST OCCUR WITHIN 60 DAYS OF THE AUTHORIZATION DATE
3. ATTORNEYS ARE RESPONSIBLE FOR PRORATING FROM THE DATE ABOVE TO THE DATE OF CLOSING. CHARGES THAT ACCRUE AFTER THIS DATE WILL BE TRANSFERRED TO THE BUYER.
CERTIFICATION AUTHORIZED BY: ____________________________________________ AUTHORIZATION DATE: ____/____/______ FPC COMPLETION DATE: ____/____/______
ACKNOWLEDGMENT
- Applicant, as named above, requests that the City of Chicago update its billing records to reflect the transfer or pending of the premises that is the subject of this Application. Applicant agrees to pay the amount for water service listed above plus $50.00 processing fee.
If new service charges accrue to the account prior to transfer of ownership of the subject property, the Department of Finance reserves the right to recalculate the balance owed. Under penalties provided by law pursuant to Section 1-109 of the Code of Civil Procedure, Applicant certifies that the
statements set forth in this document are true and correct. Applicant acknowledges that persons who make material false statements may be fined not less than $500, nor more than $1,000, plus three times the City's damages, litigation costs, collection costs, and attorney's fees pursuant to Section
1-21-010 of the Municipal Code of Chicago.
Applicant, affirms that he, she or it acquired the property listed above pursuant to a judicial deed subsequent to a judicial foreclosure action. The Full Payment Certificate that transfers the above listed premises due to a Judicial Deed to the above named Grantee will reflect zero balance as of the
execution date shown on the Judicial Deed. This Full Payment Certificate does not relieve the above listed Grantee of any service charges that have accrued or will accrue after the execution date of Judicial Deed.
This full payment certificate applies only to the water account specifically listed in this box.
Initial here if property acquire pursuant to judicial deed
IMPORTANT INFORMATION AND INSTRUCTIONS FOR COMPLETING THIS APPLICATION ARE PROVIDED ON THE BACK OF THIS FORM.
White - Cashier’s Copy
Yellow - Customer’s Copy
Pink - Audit Units Copy
Gold - Data Processing’s Copy
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