Form 01-136 - Credit Memo Acceptance
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101-136
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CLEAR FIELDS
(Rev.2-17/6)
Credit Memo Acceptance
You have certain rights under Chapters 552 and 559, Government Code, to review, request and correct information we have on file about you. Contact us
at the address or phone number listed on this form.
Name of purchaser, firm or agency accepting credit memo
Address (Street address, P.O. Box or Route number)
Daytime phone (Area code and number)
City
State
ZIP code
I, as the authorized representative for the party named above, accept credit memo number _________________
dated _______________________ in the amount of $ _________________ . This credit memo was issued to us
by _________________________________________________________ , our vendor, to cover sales or use tax
collected from us on invoice number(s) __________________________________________________________ ,
by the vendor, dated ________________________________________________________________________ .
I understand that this credit memo is being issued in lieu of a cash refund from the vendor or the State of Texas and
will be credited against my account. This credit memo is unqualifiedly accepted in full and final settlement of the
refund due us for sales or use taxes regardless of any subsequent actions taken by the vendor in regard to it.
__________________________________________________
Print or type name
__________________________________________________
Relationship to Entity (i.e., President, Treasurer)
__________________________________________________
Signature
__________________________________________________
Date
For detailed refund request instructions, please refer to Pub. How to Get a Refund or Credit for Sales or Use Tax You Paid in Error, or call the
Sales and Motor Vehicle Tax Refund Section at the Texas Comptroller’s office at 1-800-531-5441, ext. 3-4545, or 512-463-4545. You may also
email us at refundreq.revacct@cpa.texas.gov.
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