Claim For Refund - Colorado Department Of Revenue - 2013
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1CLAIM FOR REFUND
City and County of Denver
Department of Revenue – Refunds
201 W. Colfax Ave. MC 405 Dept 1009
Denver, Colorado 80202
Phone: (720) 913-9394
Fax: (720) 913-9470
_____ Sales Tax
Occupational Tax _____
_____ Use Tax
Lodger’s Tax _____
_____ TBT
License Fee _____
_____ FDA
PLEASE PRINT:
Licensed Taxpayer Claims – (Claims filed by taxpayers licensed with the City and County of Denver)
Name of Claimant _____________________________________________ Ph. # (
)______________________
Address ____________________________________________________________________________________
Street
City
State
Zip
Contact Person ________________________________________ E-mail:________________________________
Amount of Claim for Refund $ _______________ Tax Paid on Account # _________________________
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. # (
)______________________
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.
_______________________________________________________
______________________
Signature of Claimant
Date
_______________________________________________________
Print Name
OFFICIAL USE ONLY
Adjustments Total $_________________ Denied Total $_________________Interest Total $_________________
REFUND AMOUNT APPROVED $ ________________________
AUDITOR _____________________________________________Date____________________
REVIEWER____________________________________________Date____________________
REVIEWER____________________________________________Date____________________
DIRECTOR ____________________________________________Date____________________
Rev 11/2013
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