Form 21944 - Claim For Refund Of City Or County Sales And Use Tax Transmittal - 2009

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North Dakota Office of State Tax Commissioner
Claim for Refund of City or County
Sales and Use Tax Transmittal
For Office Use Only
Attach supporting documents
Acct . # _______________________
Read instructions
Social Security Number or Federal Employer Identification Number
Name
Address
City
State
Zip Code
To obtain a refund of city or county sales and use taxes, list qualifying purchases made after September 30, 2005, on
which you have remitted payment to the seller. To qualify, the local tax paid on each purchase must be in excess of the
defined city or county cap. See Instructions on back.
Note: Enter one invoice per line. Copies of all invoice(s) must be provided with refund claim.
INVOICE
INVOICE
INVOICE
INVOICE
SELLER'S
SELLER'S
DATE
NUMBER
NAME
DATE
NUMBER
NAME
If you have additional transactions to report, list on separate schedule and attach to Claim for Refund.
Refund requests will be processed immediately upon receipt. Copies of all invoices must accompany your request. Questions
regarding the refund of tax may be directed to the Sales & Special Taxes at 701-328-1246 or salestax@nd.gov.
Under penalties of law, I declare that the amount of city or county sales or use tax for which I am submitting this claim for refund has
NOT been refunded or credited to me by the Office of State Tax Commissioner or the seller to whom the tax was previously paid. If a
duplicate payment is received, I will immediately send payment for such duplicate payment to the North Dakota Office of State Tax
Commissioner.
Taxpayer Signature
Date
Phone Number
Contact: Phone: 701.328.1246
Mail To: North Dakota Office of State Tax Commissioner
E-mail: salestax@nd.gov
Sales & Special Taxes
Web site:
600 E. Boulevard Ave. Dept. 127
Bismarck, ND 58505-0599
21944
(Form revised 01/09)

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