Petition For Refund
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1
2SUBT: RP
A
D
R
Pay $__________________
LABAMA
EPARTMENT OF
EVENUE
10/11
The facts set out in this petition and the
B
L
T
D
USINESS AND
ICENSE
AX
IVISION
records of this office justify a refund in the
amount shown above.
Petition For Refund
Reset
________________ /______
Manager
Date
NOTE: Separate Petitions are Required For Each Type of Tax
FOR OFFICE USE ONLY
The undersigned hereby makes application for refund of _____________________________________________________________
_____________________________________________________________________________ Dollars, ($___________________________)
___________________________________________________________________ tax/fee paid by said undersigned to the Alabama
Department of Revenue for the period(s) ______________________________________________________________________________
________________________________________________________________________________ , which amount was erroneously paid,
or paid in excess of the amount due, or was paid through mistake of fact or law.
Explain in detail the reasons for refund claim (attach additional pages if necessary):
Petition
_____________________
Adjustment
_____________________
Interest
_____________________
Amount To
Be Refunded
_____________________
Documentation: The petition must be documented and you must attach invoices,
FOR OFFICE USE ONLY
receipts and other documentation sufficient to justify the issuance of a refund.
Signatures: If a petitioner is an individual, the individual must sign. If a petitioner is a partnership, a partner must sign. If a
petitioner is a corporation, an officer of the corporation must sign.
PETITIONER’S NAME
ACCOUNT NUMBER
FEIN/SSN
(
)
D/B/A
TELEPHONE NUMBER
PETITIONER’S SIGNATURE
PETITIONER’S TITLE
MAILING ADDRESS
CITY
STATE
ZIP CODE
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Parent category: Financial