Form - Ia 843 - Claim For Refund - Iowa Department Of Revenue - 2013
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Iowa Department of Revenue
IA 843 Claim for Refund
Sales, Use, Excise, and Local Option Tax
NAME
BUSINESS NAME
CURRENT MAILING ADDRESS
CITY, STATE, ZIP
SOCIAL SECURITY NUMBER
SALES OR USE TAX PERMIT NUMBER
FEDERAL EMPLOYER IDENTIFICATION NUMBER
COUNTY NUMBER
CHECK THE BOX corresponding to the type of refund you are claiming. Complete all sections on the form.
See instructions for documentation required to support claim.
Retail Sales Tax
Vehicle One-time Registration Fee:
Enter your Vehicle Identification Number (VIN):
Fuel Used in Implement of Husbandry
Local Option Sales Tax: Complete the schedule on the second page.
Fuel Used in Processing
Local Hotel / Motel Tax
Machinery, Equipment, and Computers
Automobile Rental Tax
Retailer’s Use Tax
State Excise Tax:
Lodging
Certain Construction Equipment
Consumer’s Use Tax
Biodiesel Production
CLAIM PERIOD ______________ TO _____________ Break down claim period by quarters. Attach additional sheets if necessary.
TAX PERIOD
ORIGINAL IOWA TAX PAID
CORRECTED AMOUNT
TAX TO BE REFUNDED
(no local option sales tax)
1. Column Subtotals
2. Subtotal from reverse side of Local Option Sales Tax Refund
3. TOTAL REFUND DUE: Add subtotals.
REASON FOR REFUND REQUEST: Explain in detail the reason(s) a refund is due, including applicable Code section and rule
references. Attach an additional sheet if needed. __________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
THE IA 843 SHOULD BE THE FIRST PAGE OF A SUBMITTED CLAIM, WITH ALL SUPPORTING DOCUMENTATION BEHIND - SEE
INSTRUCTIONS FOR SUPPORTING DOCUMENTATION REQUIREMENTS.
I, the undersigned, declare under penalty of perjury that I have examined this claim, including all accompanying schedules, documentation, and
statements, and, to the best of my knowledge and belief, it is a true, correct, and complete claim.
CLAIMANT’S SIGNATURE: _________________________________ DATE: ______________ PHONE NUMBER: __________________________
PRINT NAME: ___________________________________________ TITLE (IF CORPORATION): _______________________________________
22-009a (07/01/13)
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