Form Ia 843 - Claim For Refund
ADVERTISEMENT
1
2Iowa Department of Revenue
IA 843 Claim for Refund
FOR OFFICE USE ONLY
DLN
Sales, Use, Excise, and Local Option Tax
CONTROL NUMBER
NAME
TOTAL REFUND
BUSINESS NAME
500#
EXAM DATE
DUP
CURRENT MAILING ADDRESS: STREET OR RURAL ROUTE OR BOX NO.
COMMENTS
CITY OR TOWN, STATE, ZIP CODE
SOCIAL SECURITY NUMBER
SALES OR USE TAX PERMIT NUMBER
FEDERAL EMPLOYER IDENTIFICATION NUMBER
COUNTY NUMBER
CHECK THE BOX correspondng to the type of refund you are claiming. Complete all sections on the form.
See instructions for documentation required to support claim.
Vehicle One-time Registration Fee/Vehicle Use Tax:
Retail Sales Tax
Enter your VIN number:
Fuel Used in Implement of Husbandry
Local Option Sales Tax: You must complete the schedule on the second page.
Fuel Used in Processing
Local Hotel / Motel Tax
Machinery, Equipment, and Computers
Automobile Rental Tax
Retailer’s Use Tax
State Excise Tax:
Lodging
Certain Construction Equipment
Consumer’s Use Tax
CLAIM PERIOD ______________ TO _____________ Break down claim period by quarters. Attach additional sheets if necessary.
TAX PERIOD
ORIGINAL IOWA TAX PAID
(no local option)
CORRECTED AMOUNT
TAX TO BE REFUNDED
1. SUBTOTALS:
2. Subtotals: Combined School and Regular Local Option Tax Refund from reverse side
3. TOTAL REFUND DUE: Add subtotals.
REASON FOR REFUND REQUEST: Explain in detail the reason(s) a refund is due, including applicable Code section and rule
references. Attach an additional sheet if needed. __________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
ATTACH ALL SUPPORTING DOCUMENTATION AS REQUIRED. SEE INSTRUCTIONS.
I, the undersigned, declare under penalty of perjury that I have examined this claim, including all accompanying schedules, documentation, and
statements, and, to the best of my knowledge and belief, it is a true, correct, and complete claim.
CLAIMANT’S SIGNATURE: _________________________________ DATE: ______________ PHONE NUMBER: __________________________
PRINT NAME: ___________________________________________ TITLE (IF CORPORATION): _______________________________________
22-009a (08/05/09)
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Financial