Form R-1349 - Pollution Control Equipment Sales/use Tax Exemption/refund Application Page 7

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R-1349 (2/13)
Page ___ of ___
Applicant Name: _______________________________________________________ Applicant LDR Account Number: ______________________________________________
Project Name: _________________________________________________________ Refund Periods: ___________________________________________________________
PURCHASED BY APPLICANT AND TAXES PAID TO VENDOR
Delivery
Purchase
Vendor Name
Vendor Invoice No.
Description
4% State Tax Paid
Date
Amount
Page Total
Page Total
Total From Other Schedule B Pages
Total From Other Schedule B Pages
PURCHASES GRAND TOTAL
TOTAL SCHEDULE B REFUND REQUEST

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