Form St-Ewr - Claim For Sales Or Use Tax Refund - Extended Warranty Purchased With Motor Vehicle

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CLAIM FOR SALES OR USE TAX REFUND
EXTENDED WARRANTY PURCHASED WITH MOTOR VEHICLE
This form is used only for extended warranties purchased on motor vehicles where the sales or use tax was
paid directly to a Revenue Office on or after July 7, 1991. No refund will be made for tax paid before that date.
A separate form must be used for each warranty purchased. Refunds of sales tax paid to a dealer for a
warranty purchased separately from the motor vehicle must be requested from the dealer.
See reverse
side of this form for detailed instructions.
Name:
Address:
City:
State:
Zip:
I have enclosed (item 1) a copy of the sales tax receipt reflecting that tax was paid on the vehicle and
warranty, and (item 2) a copy of a document (bill of sale or financing agreement) that shows the purchase
price of the vehicle and extended warranty. I understand that if there is a joint ownership shown on the tax
receipt, this claim is made on behalf of all owners and that I may be liable for repayment of tax not legally due
me. Separate claims from joint owners shall not be allowed.
___________________________________________
__________________________
(Signature of Claimant)
(Date)
___________________________________________
__________________________
(Claimant’s Printed Name)
(Telephone #)
-
-
Claimant’s Social Security Number:
Mail this form and required documents to: Warranty Refund, P.O. Box 8054, Little Rock, AR 72203
Claims must be postmarked or received by December 31, 1999. Failure to provide the requested information
will delay your refund.
*******************************************************************************************************************
Do Not Complete, For Office Use Only:
-
Official Receipt #:
-
-
Date Tax Paid:
,
.
Warranty Cost:
Examined by _________
Date________________
Status______________
FORM
ST-EWR (R 03/97)

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