School District Surcharge Refund Claim Page 2

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SIGNATURES: If you checked line 2 or 4, and you are married to the same spouse, you both
must sign.
__________________________________
__________________________________
You
Your Spouse
Return this claim to DFA-Surcharge Refund Claim, P.O. Box 8149, AR 72203. Your claim must
be postmarked on or before July 31, 2001. A refund check should be issued to you within 60
days. Court ordered attorney’s fees equal to one-third of the tax and interest you are due must be
paid to Lewis & Associates, Inc. under an assignment of judgment from Oscar Stilley, the
attorney for the taxpayers. Your refund may be offset to pay an existing income tax debt.
Note: The AR1000F is the full year resident long form; the AR1000N is the non resident or part
year resident form.

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