Form Ia 843 - Claim For Refund - 2002
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Iowa Department of Revenue
IA 843 Claim for Refund
FOR OFFICE USE ONLY
DLN
Sales, Use, Local Option, Withholding
CONTROL NUMBER
NAME
TOTAL REFUND
BUSINESS NAME
500#
EXAM DATE
DUP
CURRENT MAILING ADDRESS: STREET OR RURAL ROUTE OR BOX NO.
COMMENTS
CITY OR TOWN, STATE, ZIP CODE
SOCIAL SECURITY NUMBER
SALES OR USE TAX PERMIT NUMBER
FEDERAL IDENTIFICATION NUMBER
COUNTY NUMBER
CHECK THE BOX correspondng to the type of refund you are claiming. Complete all sections on the form.
See reverse side for documentation required to support claim.
Retail Sales Tax
Fuel Used in Implement of Husbandry
Fuel Used in Processing
Machinery, Equipment, and Computers
Consumer’s Use Tax
Retailer’s Use Tax
Vehicle Use Tax: Enter your VIN number: __________________________________
Local Option Sales Tax: You must complete the schedule on the reverse side.
Withholding Tax
CLAIM PERIOD ______________ TO _____________ Break down claim period by quarters. Attach additional sheets if necessary.
TAX PERIOD
ORIGINAL IOWA TAX PAID
(no local option)
CORRECTED AMOUNT
TAX TO BE REFUNDED
1. SUBTOTALS:
2. Subtotals: Combined School and Regular Local Option Tax Refund from reverse side
3. TOTAL REFUND DUE: Add subtotals.
REASON FOR REFUND REQUEST: Explain in detail the reason(s) a refund is due, including applicable Code section and rule
references. ________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
ATTACH ALL SUPPORTING DOCUMENTATION AS REQUIRED. SEE INSTRUCTIONS.
I, the undersigned, declare under penalty of perjury that I hvae examined this claim, including all accompanying schedules, documentation and
statements, and, to the best of my knowledge and belief, it is a true, correct and complete claim.
CLAIMANT’S SIGNATURE _________________________________ DATE _______________ PHONE NUMBER __________________________
PRINT NAME ____________________________________________ TITLE (IF CORPORATION) ______________________________________
22-009a (8/13/02)
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