Tax Division - Claim For Refund Form - Commerce City, Colorado
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1FOR OFFICE USE ONLY
Date Needed:
/
/
Charge Acct #: 010-445-009
Payment Instructions:
7887 East 60th Avenue
Return check to: ____________
Commerce City, Colorado 80022
Mail check: □
(303) 289-3628 Phone
Return paperwork to Joy
(303) 289-3661 Fax
Logos vendor # :
Tax Division
Claim for Refund
(Please Type or Print Clearly)
1.
Account Number:
(Account or Building Permit Number for which refund is claimed)
2.
Name of Claimant:
3.
Mailing Address:
4.
City:
State:
Zip:
5.
Contact Name:
Telephone Number:
The undersigned certifies that this statement is made on behalf of himself or the taxpayer named, that the fact given below are true
and complete, and avers that the claim should be allowed for the reasons stated below.
A.
Dates of Payment:
B.
Amount of Tax Paid:
$
C.
Correct Amount of Tax Liability:
$
D.
Amount to be Refunded:
$
E.
Reasons for Claim:
Claim for refund of a specific tax must be made within the time limits and be supported by the required documents all in accord with
the provisions of the particular ordinance relating to such tax.
Signature of Claimant
Date
Name of Firm
CITY USE ONLY
I certify that I have made an examination of the claim and facts submitted and recommend that the amount indicated herein be refunded.
$
Amount Claimed:
$
Amount of Claim Rejected:
$
Examined By:
Total Refund Allowed:
I hereby authorize the refund of
$
as recommended in the report of the examining officer.
Finance Director
Signature
Title
Date
Claim For Refund1
Update: January 18th, 2006
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