Cat Ref , Application For Cat Tax Refund

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CAT REF
Rev. 10/12
Application for
Commercial Activity Tax
Please do not
Refund
use staples.
CAT account number
FEIN/SSN
Use only UPPERCASE letters.
Reporting member's name
Street address (number and street)
City
State
ZIP code
Time period covered by the refund request (MM/DD/YY)
to (MM/DD/YY)
,
$
Total amount of refund claimed
State full and complete reasons for the above claim. You may attach additional sheets and/or supporting documentation.
Note: This application must be fi led within four years from the date of the erroneous payment of the tax. Refund applications may
only be submitted by primary registrants; members may not submit refund requests.
SIGN HERE (required)
I declare under penalty of perjury that I am the taxpayer or the taxpayer’s authorized agent having knowledge of the relevant facts in
this matter to fi le this refund application.
Signature
Date (MM/DD/YY)
Name
Title
Contact person: The taxpayer will be represented in the matter by the following individual. Please attach a Declaration of Tax
Representative (form TBOR 1), which can be found on the department’s Web site at tax.ohio.gov.
Your fi rst name
M.I.
Last name
Home address (number and street)
City
State
ZIP code
Telephone
Fax
Title
E-mail
Please send this application to: Ohio Department of Taxation,
CAT Division-CAT REF, P.O. Box 16158 Columbus, OH 43216-6158.
*This form is created pursuant to R.C. section 5751.08.

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