Sales And Use Tax Refund Application - Kansas Department Of Revenue (Page 3 of 4) in pdf

Sales And Use Tax Refund Application - Kansas Department Of Revenue Page 3

PART E- RETAILER STATEMENT

RETAILER STATEMENT

TO ALLOW PURCHASER/CONSUMER TO FILE REFUND REQUEST

DIRECTLY WITH THE KANSAS DEPARTMENT OF REVENUE

_____________________________________,

understands that _________________________________________________

Retailer (Business Name)

Purchaser/Consumer

will file a refund claim of $_______________ directly with the Kansas Department of Revenue for

Retailers’ Sales Tax

Compensating Use Tax

Retailers’ Compensating Use Tax

previously remitted under tax account number __________________________. In order to allow this to

FEIN

occur, the Retailer affimatively states that the Retailer:

(A)

will not claim a refund of the same tax included in that refund request;

(B)

agrees to provide to the Consumer or Purchaser any information or documentation in the

possession needed for submission to the Department to support or prove the refund claim;

(C)

has remitted to the state the tax sought to be refunded;

(D)

has not taken nor will take a credit for such tax; and

(E)

understands the Retailer shall be subject to the penalties of K.S.A. 79-3615(h) for any false

information provided in this statement. [$500 to $10,000 fine and one to six months

imprisonment].

___________________________________________________________

Signature of Retailer

State of Kansas

)

) SS:

County of ____________________________ )

This Retailer Statement was acknowledged before me on ______________________________, 20___

by _______________________________________as _______________________________________

Name of Signator

Official Capacity

of _____________________________________________________.

Retailer

_____________________________________________________________________

Notary Public

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Sales And Use Tax Refund Application - Kansas Department Of Revenue Page 3