Form 01-136 - Credit Memo Acceptance
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101-136
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CLEAR FIELDS
(Rev.8-12/6)
Credit Memo Acceptance
Under Ch. 559, Government Code, you are entitled to review, request and correct information we have on file about you, with limited exceptions in
accordance with Ch. 552, Government Code. To request information for review or to request error correction, contact us at the number listed below.
Name of purchaser, firm or agency accepting credit memo
Address (Street address, P.O. Box or Route number)
Daytime phone (Area code and number)
City
State
ZIP code
I, as the authorized representative for the party named above, accept credit memo number ________________
dated _______________________ in the amount of $ _________________ . This credit memo was issued to us
by ________________________________________________________ , our vendor, to cover sales or use tax
collected from us on invoice number(s) _________________________________________________________ ,
by the vendor, dated ________________________________________________________________________ .
I understand that this credit memo is being issued in lieu of a cash refund from the vendor or the state of Texas and will
be credited against my account. This credit memo is unqualifiedly accepted in full and final settlement of the refund
due us for sales or use taxes regardless of any subsequent actions taken by the vendor in regard to it.
__________________________________________________
Print or type name
__________________________________________________
Relationship to Entity (e.g., President, Treasurer)
__________________________________________________
Signature
__________________________________________________
Date
For detailed refund request instructions, please refer to our Web page at or call the
Sales Tax Refunds Verification Section at the State Comptroller’s office at 1-800-531-5441, ext. 3-4545, or 512-463-4545.
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