Claim For Refund Form - City Of Pueblo printable pdf download

_____________

CITY OF PUEBLO

Claim#

CLAIM FOR REFUND

(Please Print or Type)

NAME OF CLAIMANT ______________________________________________________ ACCOUNT# _____________

RESIDENCE OR BUSINESS ADDRESS ________________________________________________________________

STREET

CITY

STATE/ZIP

MAILING ADDRESS ________________________________________________________________________________

(IF DIFFERENT FROM ABOVE)

STREET

CITY

STATE/ZIP

PHONE# _______________________ CONTACT PERSON _______________________________________________

TAX PERIOD FROM

DATES PAID

AMOUNT OF TAX PAID

CORRECT AMOUNT OF TAX LIABILITY

AMOUNT TO BE REFUNDED

REASON FOR CLAIM

I/we declare, under the penalties of perjury, that this claim (including any accompanying schedules and statements) has

been examined by me/us, and to the best of my/our knowledge and belief is a true, correct, and complete return made in

good faith, for the purposes stated, pursuant to the ordinances of Pueblo and the Regulations issued under authority

thereof.

_________________________________________________________________________________________________

NAME OF FIRM OR EMPLOYEE, IF ANY

________________________________________________________________________________________________________________________

SIGNATURE OF TAXPAYER

DATE

SEE INSTRUCTIONS ON REVERSE SIDE

FOR INTERNAL 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)

Refund Amount Rejected ___________________________ Type of Tax/Fee Refunded ___________________________

Total Refund Allowed ______________________________

Reasons For Actions Taken __________________________________________________________________________

_________________________________________________________________________________________________

Audited By _____________________________________ Reviewed By ______________________________________

Date ___________________________________________ Date ____________________________________________

I hereby approve the refund of ___________________, as recommended and approved for payment

________________________________________________

Director Of Finance

Claim For Refund Form - City Of Pueblo