Form St-21 - Sales And Use Tax Refund Application - 2007

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KANSAS
SALES AND USE TAX REFUND APPLICATION
Complete this application using the instructions that begin on page 4. Entries are required on all fields marked with an
asterisk (*). An incomplete application and missing documentation will delay the processing of your refund.
PART A – RETAILER (VENDOR)
*Business Name
*Employer ID Number (EIN)
*Business Address
*Kansas Tax Account Number
*City, State, Zip Code
Previous Kansas Tax Account Number
*Contact Person
*Telephone Number
(
)
E-mail Address
Fax Number
(
)
‰
‰
Source of refund:
Retailer filing for tax they paid
Retailer filing for tax paid by their customer
‰
‰
Consumer filing for tax paid to a vendor
Consumer filing for tax paid directly to the state
‰
‰
Did the Consumer receive a refund or credit?
No
Yes
If yes, enclose a copy of the credit or cancelled check.
PART B – CLAIMANT (CONSUMER)
*Claimant Name
*Employer ID Number (EIN) or Social Security Number
*Claimant Address
*City, State, Zip Code
*Contact Person
*Daytime Telephone Number
(
)
E-mail Address
Fax Number
(
)
PART C – REFUND INFORMATION
Total Refund Request:
$
Check the refund type and provide applicable exemption certificates:
‰
‰
Manufacturing Machinery and Equipment,
Hospital, School, Political Subdivision Project,
K.S.A.79-3606(kk) (page 5)
K.S.A. 79-3606(d) (page 7)
‰
‰
Consumed in Production, K.S.A.79-3606(n) (page 6)
U.S. Government Project, K.S.A.79-3606(e) (page 7)
‰
‰
Ingredient or Component Part, K.S.A.79-3606(m) (page 6)
Motor Vehicle Refund (page 8)
‰
‰
Other (please explain) __________________________
Business or Retail Business Project,
_____________________________________________
K.S.A.79-3606(cc) (page 6)
YOU ARE REQUIRED TO COMPLETE PART D. RETAILER SHOULD COMPLETE PART E ON PAGE 11.
IF THE RETAILER DOES NOT RESPOND, THE CLAIMANT WILL NEED TO COMPLETE PART F (PAGE 12).
I declare under penalties of perjury that to the best of my knowledge this is a true, correct, and complete application.
__________________________________________________________________________________________________
SIGN
Signature of Retailer
Date
HERE
____________________________________________________________________________________________________________________________
Signature of Claimant
Date
9
ST-21 (Rev. 9/07)

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