Sales And Use Tax Refund Application - Kansas Department Of Revenue

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KANSAS
SALES AND USE TAX
REFUND APPLICATION
PART A- RETAILER (VENDOR)
Business Name
FEIN/SSN
Business Address
Kansas Tax Account Number
City, State, Zip
Previous Kansas Tax Account Number
Contact Person
Telephone Number
E-Mail Address
Fax Number
q Yes
q No
Did the Consumer originate this request?
q Yes
q No
Did the Consumer receive a refund or credit?
If yes, enclose a copy of the credit or cancelled check.
PART B- CLAIMANT (CONSUMER)
Claimant Name
FEIN/SSN
Mailing Address
City, State, Zip
Contact Person
Daytime Telephone Number
PART C- REFUND INFORMATION
Please check refund type
q
q
Hospital, school, political subdivision project, K.S.A. 79-3606(d)
Consumed in production, K.S.A. 79-3606(n)
q
q
US Government project, K.S.A. 79-3606(e)
Business or retail business project, K.S.A. 79-3606(cc)
q
q
Ingredient or component part, K.S.A. 79-3606(m)
Motor vehicle refund
q
q
Manufacturing machinery and equipment, K.S.A. 79-3606(kk)
Other (Please explain) ______________________________________
You are required to complete part D. Complete Part E or Part F if the Retailer elects or refuses not
to participate in the refund process. Incomplete applications will be returned.
I declare under the penalties of perjury that to the best of my knowledge this is a true, correct and complete request.
Signature of Retailer
Date
Signature of Claimant
Date
FOR OFFICE USE ONLY
Postmark Date
Original Refund Request
Date Worked
Interest Paid
Refund Allowed
Customer Representative
Notes
Page 2

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