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

Sales And Use Tax Refund Application - Kansas Department Of Revenue Page 4

PART F- CLAIMANT/CONSUMER AFFIDAVIT

AFFIDAVIT

STATE OF KANSAS

)

) SS:

COUNTY OF __________________________ )

____________________________, upon oath, affirms and states that this refund claim is being

Claimant/Consumer

submitted directly to the Kansas Department of Revenue without the participation of the Retailer for

the following reason:

the retailer is no longer in business;

the Retailer has moved, and the Consumer cannot locate the Retailer;

the Retailer is insolvent, and is financially unable to make the refund; or

the Consumer attempted in good faith to obtain a refund from the Retailer and provides documentation

that the Retailer refused or is unable to refund the tax or did not act within three months of the date of

the first refund request. (Retailers’ may be contacted)

On _____________________ the first refund request was sent to the Retailer, together with the attached

Date

documents.

_____________________________________________

Claimant/Consumer

SUBSCRIBED AND SWORN TO before me on

_______________________________________________________________

_______________________________________________________________________________.

_____________________________________________________________

Notary Public

My appointment expires: ___________________.

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Sales And Use Tax Refund Application - Kansas Department Of Revenue Page 4