Form Au-524 - Assignment Of Retailer'S Rights For Refund
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1DEPARTMENT OF REVENUE SERVICES
AUDIT DIVISION
25 SIGOURNEY STREET
HARTFORD, CONNECTICUT 06106
ASSIGNMENT OF RETAILER'S RIGHTS FOR REFUND
SCHEDULE NO._____________________
NAME OF CLAIMANT
SALES TAX PERMIT NO.
NAME OF RETAILER
SALES TAX PERMIT NO.
STREET ADDRESS, CITY OR TOWN
TAX COLLECTED
GROSS AMOUNT OF
PORTION OF SALE
AND PAID ON
DATE
INVOICE NUMBER
SALES EXCLUDING
SUBJECT TO
PORTION
ITEM SOLD
TAX
REFUND CLAIM
SUBJECT TO
REFUND CLAIM
ATTACH ADDITIONAL WORKSHEETS AS NEEDED.
DECLARATION BY RETAILER
I am the authorized representative of the retailer listed above. I declare under penalty of false statement that the figures
above are true and correct for the sales indicated; that the sales tax shown was collected from this claimant and was
remitted to the Department of Revenue Services; and that this retailer disclaims any interest in these sales taxes remitted to
the Department of Revenue Services for the period
/
/
through
/
/
. Any refunds due are
assigned to the claimant. The retailer understands that by signing this declaration it does not necessarily agree with the
refund claim. (The penalty for false statement is imprisonment not to exceed one year or a fine not to exceed two thousand
dollars, or both.)
__________________________________________________________________________________________
NAME OF RETAILER (PLEASE PRINT)
________________________________________________
_____________________________________
SIGNATURE OF AUTHORIZED REPRESENTATIVE
DATE
________________________________________________
_____________________________________
NAME OF AUTHORIZED REPRESENTATIVE (PLEASE PRINT)
TITLE (PLEASE PRINT)
THIS SCHEDULE SHALL BE ATTACHED AND MADE A PART OF SALES TAX CLAIM OF CLAIMANT
AU-524(Rev. 2/99)
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