Form St-21 - Sales And Use Tax Refund Application - 2015 Page 4

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PART F – CLAIMANT/CONSUMER AFFIDAVIT
AFFIDAVIT
This refund application is being submitted directly to the Kansas Department of Revenue without the participation of the
retailer for the following reason:
‰
The retailer is no longer in business.
‰
The retailer has moved and the Consumer cannot locate the Retailer.
‰
The Consumer attempted in good faith to obtain a refund from the Retailer and provides
documentation that the Retailer refused or is unable to refund the tax or did not act within 60 days
of the date of the first refund request. “Good Faith” means that the consumer provided the retailer
with all of the documentation and information needed to determine the validity of the refund request
and has otherwise made a reasonable attempt to obtain the refund from the retailer. This includes
making a reasonable attempt to find the correct address of the retailer. A mere request that a
retailer agrees to allow the consumer to file a refund claim directly with the department, without
completing the Assignment of Right to Refund form, shall not constitute a good faith attempt to
obtain the refund from the retailer. (Retailers may be contacted.)
A copy of the certified letter and mail receipt to the retailer must be attached to the refund request.
On _______________________________ the first refund request and required documents were sent to the retailer.
(Date)
I certify under the penalties of perjury that to the best of my knowledge, all of the information and statements made
in this affidavit are true and correct.
_________________________________________________________________________ _______________________
(Claimant/Consumer’s Signature)
(Date)
STATE OF KANSAS
)
) SS:
COUNTY OF __________________________
)
SUBSCRIBED AND SWORN TO before me on ______________________________________________, 20 ________ by
_____________________________________________________________ .
Notary Public: ________________________________
My appointment expires: _______________________________
13

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