Claim For Refund - Colorado Department Of Finance - 2016
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1
2RETURN TO:
CITY AND COUNTY OF DENVER
OR
Department of Finance – Refunds
CLAIM FOR REFUND
201 W. Colfax Ave.
MC 1001 Dept 1009
Denver, Colorado 80202
Use Tax
Lodger’s Tax
Occupational Privilege Tax
Sales Tax
Phone: (720) 913-9394
FDA
License Fee
TBT
Licensed Taxpayer Claims – (Claims filed by taxpayers licensed with the City and County of Denver)
Name of Claimant __________________________________________________ Ph. #___________________________
Refund Mailing Address_____________________________________________________________________________
Street
City
State
Zip
Contact Person ____________________________________
E-mail:________________________________
Denver Account # _______________________
Amount of Claim for Refund $ _______________________
Period(s) Being Claimed: _______________________
rd
3
Party Claims – (Claims filed by purchasers/employees not licensed with the City and County of Denver)
Must be filed within 60 days of transaction resulting in overpayment of tax – see instructions
Name of Claimant _________________________________________________ Ph. #____________________________
Refund Mailing Address ____________________________________________________________________________
Street
City
State
Zip
Contact Person ___________________________________
E-mail: _______________________________________
Amount of Claim for Refund $ ______________________
Tax Paid to: ______________________________________
Date(s) Tax Paid: _______________________________
Statement of REASON FOR REFUND CLAIM
I hereby certify, under penalty of perjury, that the statements made herein are true and correct to the best of my knowledge. I understand
that making false statements in connection with an application for refund is a violation of the Denver Revised Municipal Code and may
be punishable by fines not to exceed $999.00 and/or imprisonment of up to one (1) year.
Unsigned forms will be considered incomplete and not logged or processed.
___________________________
_______________________________________________________
Signature of Claimant
Date
_______________________________________________________
Print Name
OFFICIAL USE ONLY
Adjustments Total $_________________
Denied Total $_________________
Interest Total__________________
REFUND AMOUNT APPROVED $ ____________________________
Date_____________________
REVIEWER__________________________________________________
SUPERVISOR________________________________________________
Date_____________________
MANAGER__________________________________________________
Date_____________________
Date_____________________
DIRECTOR __________________________________________________
Rev 12/2017
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