Form Pcr - 1999 Political Contribution Refund Application - Minnesota Department Of Revenue
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1MINNESOTA Department of Revenue
1 1 1 1 1 999 Political Contribution Refund Application
999 Political Contribution Refund Application
999 Political Contribution Refund Application
999 Political Contribution Refund Application
999 Political Contribution Refund Application
PCR
PCR
PCR
PCR
PCR
for a refund of contributions to Minnesota political parties and candidates for Minnesota state offices
Your first name and initial
Last name
Social Security number
Spouse’s first name and initial (if this is a joint return)
Last name
Social Security number
Present home address (street, apartment, route)
City or town
State
Zip code
How many Minnesota receipt forms (EP-3)
are you attaching to this application?
C C C C C
h e c k o n e b o x
h e c k o n e b o x
h e c k o n e b o x (married couples: see the notice below)
(married couples: see the notice below)
(married couples: see the notice below)
(married couples: see the notice below)
(married couples: see the notice below) : : : : :
h e c k o n e b o x
h e c k o n e b o x
Single
Married, filing joint application
Married, filing separate application
You may file only one application each year. You cannot file another application for
You may file only one application each year. You cannot file another application for
You may file only one application each year. You cannot file another application for
You may file only one application each year. You cannot file another application for
You may file only one application each year. You cannot file another application for
t h e s a m e y e a r o r a m e n d a n a p p l i c a t i o n a f t e r i t h a s b e e n f i l e d .
t h e s a m e y e a r o r a m e n d a n a p p l i c a t i o n a f t e r i t h a s b e e n f i l e d .
t h e s a m e y e a r o r a m e n d a n a p p l i c a t i o n a f t e r i t h a s b e e n f i l e d .
t h e s a m e y e a r o r a m e n d a n a p p l i c a t i o n a f t e r i t h a s b e e n f i l e d .
t h e s a m e y e a r o r a m e n d a n a p p l i c a t i o n a f t e r i t h a s b e e n f i l e d .
1 1 1 1 1
Add all the contributions made in 1999 shown on the Minnesota Receipt Form(s) EP-3
attached to this application, and fill in the total . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 1 1 1 1
2 2 2 2 2
If you are a married couple filing a joint application, fill in $100. If you are
single or married but filing a separate application, fill in $50 . . . . . . . . . . . . . . . . . . . . . . 2 2 2 2 2
3 3 3 3 3
Fill in the amount from line 1 or line 2 above, w h i c h e v e r i s l e s s .
w h i c h e v e r i s l e s s .
w h i c h e v e r i s l e s s .
w h i c h e v e r i s l e s s .
w h i c h e v e r i s l e s s .
This is the amount of the refund you will receive . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 3 3 3 3
I declare that this form is correct and complete to the best of my knowledge and belief.
Your signature
Spouse’s signature (if a joint application)
Date
Daytime phone
(
)
Be sure to attach the original Minnesota Political Contribution Receipt, Form EP-3, for all your
Be sure to attach the original Minnesota Political Contribution Receipt, Form EP-3, for all your
Be sure to attach the original Minnesota Political Contribution Receipt, Form EP-3, for all your
Be sure to attach the original Minnesota Political Contribution Receipt, Form EP-3, for all your
Be sure to attach the original Minnesota Political Contribution Receipt, Form EP-3, for all your
contributions made in 1999 to one Form PCR.
contributions made in 1999 to one Form PCR.
contributions made in 1999 to one Form PCR.
contributions made in 1999 to one Form PCR.
contributions made in 1999 to one Form PCR.
MARRIED COUPLES:
MARRIED COUPLES:
MARRIED COUPLES:
MARRIED COUPLES:
MARRIED COUPLES:
• • • • • You must choose to file either a joint application or separate applications;
You must choose to file either a joint application or separate applications;
You must choose to file either a joint application or separate applications;
You must choose to file either a joint application or separate applications;
You must choose to file either a joint application or separate applications;
y o u c a n n o t f i l e b o t h .
y o u c a n n o t f i l e b o t h .
y o u c a n n o t f i l e b o t h .
y o u c a n n o t f i l e b o t h .
y o u c a n n o t f i l e b o t h .
• • • • • If you file a separate application, do not fill in your spouse's name and Social
If you file a separate application, do not fill in your spouse's name and Social
If you file a separate application, do not fill in your spouse's name and Social
If you file a separate application, do not fill in your spouse's name and Social
If you file a separate application, do not fill in your spouse's name and Social
S e c u r i t y n u m b e r a n d d o N O T h a v e y o u r s p o u s e s i g n y o u r a p p l i c a t i o n .
S e c u r i t y n u m b e r a n d d o N O T h a v e y o u r s p o u s e s i g n y o u r a p p l i c a t i o n .
S e c u r i t y n u m b e r a n d d o N O T h a v e y o u r s p o u s e s i g n y o u r a p p l i c a t i o n .
S e c u r i t y n u m b e r a n d d o N O T h a v e y o u r s p o u s e s i g n y o u r a p p l i c a t i o n .
S e c u r i t y n u m b e r a n d d o N O T h a v e y o u r s p o u s e s i g n y o u r a p p l i c a t i o n .
Mail this application no later than April 17,
Mail this application no later than April 17,
Mail this application no later than April 17, 2 2 2 2 2 000, to:
000, to:
000, to:
Mail this application no later than April 17,
Mail this application no later than April 17,
000, to:
000, to:
Minnesota Political Contribution Refund
Minnesota Department of Revenue
St. Paul, MN 55146-1800
Printed on recycled paper with 10% post-consumer waste using soy-based ink.
Stock No. 1099600
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