Form Ga-110l/state Form 615 - Claim For Refund

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Indiana Department of Revenue
Form
GA-110L
Claim for Refund
State Form 615
(R8 / 5-17)
Name of Taxpayer
Taxpayer Identification Number
Address
Federal Identification Number
City
State
Zip
Social Security Number
Indicate only one tax type from one of the following lists
Mailing/Contact Information
Corporation
Food & Beverage
Sales & Use (Utilities)
P.O. Box 935
County Innkeepers
Individual Income
Withholding
Indianapolis, IN 46206-0935
(317) 232-2339
Fiduciary
Motor Vehicle Rental
Other ______________________________
Refundclaim@dor.in.gov
Financial Institutions
Sales & Use (Not Fuel Related)
Mailing/Contact Information
Aviation Fuel Excise
Prepaid Sales on Gasoline
Other Fuel Related ___________________
P.O. Box 1971
Gasoline Use
Sales (Diesel)
Indianapolis, IN 46206-1971
(317) 615-2552
Oil Inspection Fee
Surcharge (Special Fuel - see instructions)
fetax@dor.in.gov
Mailing/Contact Information
Aeronautics
Cigarette Excise
P.O. Box 901
Alcohol Excise
Other Tobacco Products Excise
Indianapolis, IN 46206-0901
(317) 615-2710
excisetax@dor.in.gov
Mailing/Contact Information
BAS
IRP/BPR
Oversize/Overweight
P.O. Box 6075
IFTA
Motor Carrier Fuel Tax
UCR
Indianapolis, IN 46206-6075
(317) 615-7345
lndianaMotorFuel@dor.in.gov
Indicate a brief explanation as to why a refund is due:
Year or Period Ending
Requested Refund
Date(s) of Tax
Year or Period Ending
Requested Refund
Date(s) of Tax
Amount
Payment(s)
Amount
Payment(s)
Total Requested Refund Amount $
I hereby certify that the foregoing account is just and correct; that the amount claimed is legally due, after allowing all just credits; and that no part of the
same has been paid. I further understand that this refund may be applied to any liability which I currently have outstanding. Under penalties of perjury,
I declare that I have examined this form, including the accompanying schedules and statements, and to the best of my knowledge and belief it is true,
correct, and complete. (If you are claiming a refund for a year in which a joint return was filed, each spouse must sign this refund claim.)
Attach evidence to support your claim. Failure to attach all documentation with the claim may result in either a delay or the claim being denied.
____________________________________________
___________________________________
____________________________
Signature
Printed Name
Title
____________________________________________
___________________________________
____________________________
Daytime Phone Number
Email
Date
For Department Use Only
Year
Interest
Interest
Total
Total
DLN
____________________________
___________
Paid
Paid
Interest
Refund
Tax Analyst/Auditor
Date
From
To
Amount
Amount
____________________________
___________
Supervisor
Date
____________________________
___________
Commissioner/Appointee
Date
____________________________
Claim Number

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