Form 35-003a - Construction Contract Claim For Refund
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2Iowa Department of Revenue
Construction Contract Claim for Refund
NAME OF governmental unit, private nonprofit educational institution, nonprofit museum, business in economic development area, rural water district, or Habitat for Humanity
CURRENT MAILING ADDRESS
FEIN
ADDRESS 2
CITY. STATE, ZIP
COUNTY NO.
1. Description of project: _________________________________________
2. Final settlement date of contract: ____________
Claim must be filed within one year of final settlement.
3. Was contract in writing? _______ If so, date signed: _________________
4. Have you previously filed a claim for this project? ______
Items 1 – 4 and the local option tax summary on the reverse side must be completed before your claim
can be processed.
LIST CONTRACTORS AND SUBCONTRACTORS ONLY.
ATTACH ADDITIONAL SHEETS IF NEEDED.
NAME OF CONTRACTOR/
MATERIAL PURCHASES
TAX TO BE REFUNDED
SUBCONTRACTOR
AMOUNT
Iowa Sales/Use
Local Option
SUBTOTALS
TOTAL REFUND DUE:
Add Iowa sales/use tax and local option tax columns.
I, the undersigned, declare under penalty of perjury that I have examined this claim, including all attached contractors statements, and, to
the best of my knowledge and belief, it is a true, correct, and complete claim. This claim is filed pursuant to section 423.4 Code of Iowa.
Signature: ________________________________________________ Print Name: _______________________________________
Title: __________________________________ Daytime Telephone Number: ______________________ Date: _______________
SUBMIT COMPLETED FORM WITH ORIGINAL CONTRACTOR’S STATEMENTS TO:
COMPLIANCE DIVISION
IOWA DEPARTMENT OF REVENUE
PO BOX 10456
DES MOINES IA 50306-0456
35-003a (09/21/12)
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Parent category: Financial