Refund Claim For Sales Tax Paid

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00LORPP°
City and County of Broomfield
Sales Tax Administratio n
ONE DESCOMBES DRWE BROOMFIELD, Co 80020 303-464-5811
303-410-3802 (fax)
REFUND CLAIM : FOR SALES
TAX
PAI D
1) This claim form must be accompanied by supporting documentation of sales tax paid to a BROOMFIELD
vendor. Include copies of sales invoices, receipts . building permits. etc ., or any other documentation that
proves the amount of tax paid .
2) If this claim is for sales tax paid, where you have previously paid Local Use Tax on a building permit. we
will limit the refund to the amount of Use Tax paid and receipted on the permit . We do not refund State or
RID sales tax, as those taxes are not "pre-paid" on the building permit .
3) Claims for local sales tax paid to other jurisdictions will not be accepted . You must file with the other
jurisdictions .
4) This claim form must be signed and dated by the taxpayer . If the taxpayer is a corporation, the claim mus t
be signed with the corporation name, followed by the signature and title of the officer having the authority
to sign for the corporation. Incomplete forms will not be processed .
1)
Taxpayer Nam e
2)
Taxpayer DBA (If applicable)
3)
Mailing Addres s
4)
____________________________________
5)
______________
6)
_____________________
City State Zip code
7)
_________________________________
8)
______________
9)
______________________
Original Amount Paid Correct Amount Refund Requeste d
10) Reason for claint Supnorting documentation must be attached ;
11) 1 declare under penalty of perjury in the second degree that this claim, including all attachments, is true an d
correct to the best of my knowledge :
12) _____________________________________________ 13) __________________________________
Signature Date Signature of Preparer (if other than taxpayer )
14) ___________________________________________
15) _________________________________
Title Telephone # Fax #
16)
_________________________________________
17)
__________________________________
Name of Firnr Telephone # Fax #
18)
___________________________________________ 19) __________________________________ _
Email address Date

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