Form St-5 - Direct Petition For Refund 2011
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1
2ST-5
A
D
R
LABAMA
EPARTMENT OF
EVENUE
9/2011
Reset
Pay $__________________
S
U
T
D
ALES AND
SE
AX
IVISION
The facts set out in this petition and the
A
S
DMINISTRATION
ECTION
records of this office justify a refund in the
amount shown above.
Direct Petition For Refund
NOTE: Separate Petitions are Required
______ /______ /______
For Each Type of Tax
______ /______ /______
DATE RECEIVED: ____/____/______
DATE APPROVED
FOR OFFICE USE ONLY
FOR OFFICE USE ONLY
The undersigned hereby makes application for refund of _____________________________________________________________
_____________________________________________________________________________ Dollars, ($___________________________)
_____________________________________________________ tax paid by said undersigned to the Alabama Department of Revenue
for the period(s) ___________________________________________________________ which amount was erroneously paid, paid in
excess of the amount due, or was paid through mistake of fact or law.
___________________________________________________________________________________________________________________
Explain in detail the reasons for refund claim (attach additional pages if necessary):
Petition
_____________________
Adjustment
_____________________
Discount
_____________________
Interest
_____________________
Transfer
_____________________
Total Amt. To
Be Refunded
_____________________
FOR OFFICE USE ONLY
PETITIONER’S LEGAL NAME
ACCOUNT NUMBER
FEIN
DOING BUSINESS AS (IF APPLICABLE)
TELEPHONE NUMBER
PETITIONER’S SIGNATURE *PLEASE SEE NOTE BELOW.
PRINT PETITIONER’S NAME
PETITIONER’S TITLE
MAILING ADDRESS
CITY
STATE
ZIP CODE
* NOTE: Must be signed by an Officer, Owner, Partner or Legal Representative.
(Instructions on Page 2)
Page 1 of 2
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