Form Et-179a - Claim For Local Tax Rebate
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3ARKANSAS DEPARTMENT OF FINANCE AND ADMINISTRATION
CLAIM FOR LOCAL TAX REBATE FORM ET-179A
■ Attach Supporting Documents
■ Read Instructions
Sales Tax Permit #
1) Company Name
2) FEIN
3) Mailing Address
4) City
5) State
6) Zip
If you do not have an Arkansas Sales Tax Permit Number, complete the following section.
7) Owner's Name
8) NAICS Code of Business
9) Type of Ownership
10) Location Address
11) City
12) State
13) Zip
14) Contact Name
15) Contact Phone Number
Please complete the section below with information from the sales invoices on which you are claiming the local tax rebate. Please Note: Information provided on this form will be subject to Audit. Information
found to be fraudulent will result in loss of your local tax rebate and assessment of penalties.
22) Invoice Amount
18) City/County Where
20) Invoice Total Amount
16) Invoice Number
17) Invoice Date
19) City/County Tax Code
21) Standard Cap Amount
Eligible for Rebate (Block
23) Local Tax Rate
24) Rebate Amount
Purchased or Delivered/Shipped
(Do Not Include Tax Paid)
20 minus Block 21)
- $2,500.00 =
25,000.00
5,000.00
10.0000
2,500.00
X
% =
- $2,500.00 =
-2,500.00
X
% =
- $2,500.00 =
-2,500.00
X
% =
- $2,500.00 =
-2,500.00
X
% =
- $2,500.00 =
-2,500.00
X
% =
- $2,500.00 =
-2,500.00
X
% =
25) Rebate Claim Amount (From Invoice(s) Listed
25,000.00
Above)
26) Rebate Claim Amount (Local Tax Rebate
Supplemental Sheet Total)
27) Total Rebate Claim Amount
25,000.00
(Combine Line 25 and 26)
Under penalties of law, I declare that the amount of sales or use tax for which I am submitting this claim for refund has NOT been refunded or credited to me by the Department or the seller to whom the tax was
previously paid. I will immediately send payment for any such duplicate refund to the Arkansas Department of Finance & Administration; PO Box 3566, Little Rock, AR 72203-3566.
28) Signature
29) Date
Mail To: SALES & USE TAX SECTION
Contact:
Phone: 501-682-7105
P O. BOX 3566
Fax: 501-682-7904
LITTLE ROCK, AR 72203-3566
Web site:
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