Claim For Refund Form - City Of Westminster Sales Tax Division
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1City of Westminster
Claim for Refund
Department of Finance
Sales Tax Division
Please Type or Print Clearly
1) Legal Name of Business or Individual Name (Last, First):
2) Trade Name of Business (if any):
7) Contact Person (if Business):
3) Mailing Address:
8) Phone Number:
4) City:
5) State:
6) Zip:
9) City Account Number:
$
10) Amount of Claim:
11) Date(s) of Overpayment:
Sales
Use
Admissions
Accommodations
Other:____________________
12) Tax Type(s):
13) Give a brief explanation of your claim. Attach supporting documentation such as invoices, tax returns, supporting schedules, permits, etc. If the refund is
to be mailed to an address other than the address on file with the Sales Tax Division, include an explanation of why the alternate address should be used.
Attach additional sheets if necessary.
Under penalty of perjury, I declare that I have examined this Claim for Refund and that it is true and correct to the best of my knowledge and belief.
Claimant
Signature
Date
Signature
Printed Name
Title
Phone No.
Westminster Department of Finance Sales Tax Division 4800 W 92nd Avenue Westminster, CO 80031
Return completed form to:
(303) 658-2065 Fax: (303) 706-3923
CITY USE ONLY
R-
CLAIM NO.
CASHIER VALIDATION
Reviewed By:
(If Petty Cash)
Signature
Date
Denied
Approved
Approved in Part: $________________
Disposition:
Approved By:
Signature
Date
Finance Director:
Signature (Required if Over $15,000)
Date
5300.____________.0000 Amount:
ACCOUNTS
5400.____________.0000 Amount:
5300.____________.0911 Amount:
Petty Cash Rcvd By:_________ Date:______
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