A-3730
State of New Jersey
For Official Use Only
(11-10)
Claim No.
Division of Taxation
CLAIM FOR REFUND - BUSINESS TAXES ONLY
Please Print or Type / See Instructions On Reverse Side
DO NOT USE THIS FORM FOR GROSS INCOME TAX (Individual)
COMPLETE ALL APPLICABLE ITEMS
SECTION ONE
1a. Name of Taxpayer
1b. Trade Name
All correspondence related to this claim will be mailed to the address listed in 2a, 2b, 2c, and 2d below. If you are using a Taxpayer
Representative, you must submit the Taxpayer Representative’s address on the Appointment of Taxpayer Representative form (M-5008-R).
2a. Number and Street
2b. City
2c. State
2d. Zip Code
3. FID Number or Social Security Number
4. Name and Address on Return (if different from above)
5. Type of Tax
6. Period Covered by Claim
7. Date of Payment
8. Amount of Claim
SECTION TWO
EXPLANATION OF CLAIM
In accordance with N.J.A.C. 18:2-5.8, submit a detailed explanation as well as all supporting documentation to substantiate this claim. If space is
insufficient, submit additional sheets.
COMPUTATION OF CIGARETTE TAX REFUNDS
License No._______________________________
Number of Packages
Brand
Denomination of Stamps
Value of Stamps
$
Total
Less Discount
Net Refund Amount
SECTION THREE
I declare under the penalties of perjury that this claim (including any accompanying schedules and statements) has been examined by me and to the
best of my knowledge and belief is true and correct.
Signature
Title of Signing Officer
Printed Name of Signing Officer
Contact Phone Number
Date