Form Ador 91-0077 - Notice Of Claim By Federal Employee - 2003

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Notice of Claim by Federal Employee
I hereby claim a refund of any Arizona income tax paid on federal retirement plan contributions made in the indicated years:
1999
2000
2001
2002
2003
YOUR FIRST NAME AND INITIAL
LAST NAME
YOUR SOCIAL SECURITY NO.
1
IF A JOINT RETURN, SPOUSE’S FIRST NAME AND INITIAL
LAST NAME
SPOUSE’S SOCIAL SECURITY NO.
1
PRESENT HOME ADDRESS - NUMBER AND STREET, RURAL ROUTE APT. NO. DAYTIME PHONE: (
)
IMPORTANT
2
You must enter your SSNs.
94
HOME PHONE: (
)
FOR DOR USE ONLY
CITY, TOWN OR POST OFFICE
STATE
ZIP CODE
3
88
_________________________________________________
________________________
81
Signature
Date
Do not mail this claim with your 2003 income tax return. Mail this claim separately to:
Federal Employee Protective Claim
Arizona Department of Revenue
PO Box 29201
Phoenix, AZ 85038-9201
ADOR 91-0077 (10/03)

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