Form R-1349 - Pollution Control Equipment Sales/use Tax Exemption/refund Application Page 6
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9R-1349 (2/13)
Page ___ of ___
Applicant Name: _______________________________________________________ Applicant LDR Account Number: ______________________________________________
Project Name: _________________________________________________________ Refund Periods: ___________________________________________________________
PURCHASED BY APPLICANT AND NO TAXES PAID TO VENDOR
State Tax Accruals
Delivery
Purchase
Vendor Name
Vendor Invoice No.
Description
Period Tax Accrued
Tax Amount Accrued
Date
Amount
Page Total
Page Total
Total From Other Schedule A Pages
Total From Other Schedule A Pages
PURCHASES GRAND TOTAL
TOTAL SCHEDULE A REFUND REQUEST
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