Form Ga-110l - Claim For Refund Form
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BATCH & ITEM NUMBER
FORM
Indiana Department of Revenue
GA-110L
Claim For Refund
WARRANT NUMBER & DATE
State Form 615
(R/ 03-98)
Identification Numbers
TYPE OF BUSINESS:
Individual
Partnership
Corporation
Other
Name of Taxpayer
Social Security Number
Address
Federal Identification Number
City
State
Zip
Taxpayer Identification Number
!
CHECK TAX TYPE
Hazardous Chemical
Motor Carrier
Sales & Use
IFTA
MVR-Excise
Prepaid Sales on Gasoline
Fiduciary
Charity Gaming
Individual
Oil Inspection
Special Fuel
Financial Institutions
Cigarette
Food & Beverage
Inheritance
Other
Underground Storage
Corporation
Gasoline
IRP
Overersize/Overweight
Withholding
County Innkeepers
Explanation of claimed refund. Please attach supporting documentation and/or additional
Year or
Requested Refund
Date(s) of Tax
sheets (if necessary) .
Amount
Payment(s)
Period Ending
Total
I hereby certify that the foregoing account is just and correct; that the amount claimed is legally due, after allowing all just credits, and that no part of the same has
been paid. I further understand that this refund may be applied to any liability which I currently have outstanding. Under penalties of perjury, I declare that I have
examined this form, including accompanying schedules and statements, and to the best of my knowledge and belief it is true correct and complete. If you are claiming
a refund for a year in which a joint return was filed, each spouse must sign this refund claim.
(
)
Signature
Title
Date
Daytime Telephone Number
(Please Check)
Individual
Partner
Corporate Officer
Power of Attorney (Please Attach POA)
Indiana Department of Revenue, Indiana Government Center North
Mail completed form to:
100 N. Senate Avenue, Indianapolis, IN 46204-2253
THE SPACE BELOW IS FOR DEPARTMENT USE ONLY
District of tax payment:
County of tax payment:
Interest
B & I Number of Return
Amount
Amount Previously
Interest
Total
Amount Claimed
Year
Interest
Paid To:
or Liability Number
Paid
Refunded or Transferred
Paid From:
Refunded
as Refund
TOTAL AMOUNT OF REFUND
Date
Auditor/Examiner Originating Refund
Supervisor/Administrator
Date
Date
Commissioner/Appointee
Account Number
Claim Number
User Identification Number
Special
Signature on File
Reset
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Parent category: Financial