Form Au-524 - Assignment Of Retailer'S Rights For Refund 2015
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1DEPARTMENT OF REVENUE SERVICES
AUDIT DIVISION
25 SIGOURNEY STREET
HARTFORD, CONNECTICUT 06106
ASSIGNMENT OF RETAILER'S RIGHTS FOR REFUND
NAME OF CLAIMANT (BUSINESS ENTITY OR INDIVIDUAL CLAIMING REFUND)
CT SALES TAX I.D.#
COMPLETE NAME OF RETAILER
CT SALES TAX I.D.#
STREET ADDRESS, CITY OR TOWN, STATE, AND ZIP CODE
TAX COLLECTED
GROSS AMOUNT OF
PORTION OF SALE
AND PAID ON
INVOICE DATE
INVOICE NUMBER
SALES EXCLUDING
SUBJECT TO
PORTION
ITEM SOLD AND REASON FOR REFUND
TAX
REFUND CLAIM
SUBJECT TO
REFUND CLAIM
ATTACH ADDITIONAL WORKSHEETS AS NEEDED.
DECLARATION BY RETAILER
I am the authorized representative of the retailer listed above. I declare under penalty of false statement that the figures above
are true and correct for the sales indicated; that the sales tax shown was collected from this claimant and was remitted to the
Department of Revenue Services; and that this retailer disclaims any interest in these sales taxes remitted to the Department
of Revenue Services for the period
/
/
through
/
/
. Any refunds due are assigned to the claimant.
The retailer understands that by signing this declaration it does not necessarily agree with the refund claim. (The penalty for
false statement is imprisonment not to exceed one year or a fine not to exceed two thousand dollars, or both.)
__________________________________________________________________________________________
NAME OF RETAILER (PLEASE PRINT)
________________________________________________
_____________________________________
SIGNATURE OF AUTHORIZED REPRESENTATIVE
DATE
________________________________________________
_____________________________________
NAME OF AUTHORIZED REPRESENTATIVE (PLEASE PRINT)
TITLE (PLEASE PRINT)
THIS SCHEDULE SHALL BE ATTACHED AND MADE A PART OF THE SALES TAX CLAIM OF CLAIMANT.
AU-524 (Rev. 8/15)
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