Application For Sales/use Tax Refund Form - Ohio Department Of Taxation Page 2
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3ST AR
Rev. 8/13
9. I hereby attest that I am the taxpayer(s) or their authorized agent. I declare under penalties of perjury that this claim
(including any accompanying schedules and statements) has been examined by me and to the best of my knowledge
and belief is true, correct and complete.
The taxpayer(s) will be represented in this matter by:
Name
Applicant name/title
Address
Signature
Date
Telephone
Fax
Telephone
Fax
E-mail
E-mail
May we contact you via secure e-mail at the e-mail address above with account information and/or any additional requests
pertaining to your application? Yes
No
FOR OFFICE USE ONLY
Field Investigation
Date completed
Amount recommended
Agent
Group supervisor
Audit review
Reviewer
Central Offi ce Processing
Claimed
Inc/red
Deallocation
Xfer tax
TOS Ck
Xfer int
Net to txpr
Approved: Date
Agent
Int to txpr
Txpr ck
Reviewed: Date
Agent
Total approved
- 3 -
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