Form Ga-110l - Claim For Refund
Download a blank fillable Form Ga-110l - Claim For Refund in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form Ga-110l - Claim For Refund with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2Form
Indiana Department of Revenue
Mail to: P.O. Box 935
GA-110L
Claim for Refund
Indianapolis, IN 46206-0935
State Form 615
Call (317) 232-2339 or
(R6 / 6-13)
refundclaim@dor.in.gov
email
Taxpayer Identification Number
Name of Taxpayer
Federal Identification Number
Address
Social Security Number
City
State
Zip
□
□
□
□
Fiduciary
Hazardous Chemical
MVR-Excise
Check One Tax Type
Sales & Use on Utilities
□
□
□
□
□
Aviation Fuel Excise
Financial Institutions
Oil Inspection
Underground Storage
IFTA
□
□
□
□
□
Individual
Oversize/Overweight
Withholding
Cigarette
Food & Beverage
□
□
□
□
□
Gaming Excise
Other ___________________
Corporation
IRP
Prepaid Sales on Gasoline
□
□
□
□
County Innkeepers
Gasoline Use
Motor Carrier
Sales & Use
Attach ALL documentary evidence to support your claim. Failure to attach all documentation with the claim may result in the claim being rejected or
denied. (Please check the box after completing).
□
A completed explanation is required as to why the refund is due.
□
A Power of Attorney (POA-1) form must be completed and attached authorizing the department to discuss your claim and specific tax type with
anyone other than the taxpayer.
Requested Refund
Date(s) of Tax
Requested Refund
Date(s) of Tax
Year or Period Ending
Year or Period Ending
Amount
Payment(s)
Amount
Payment(s)
Total Requested Refund Amount $
I hereby certify that the foregoing account is just and correct; that the amount claimed is legally due, after allowing all just credits; and that no part of
the same has been paid. I further understand that this refund may be applied to any liability which I currently have outstanding. Under penalties of
perjury, I declare that I have examined this form, including the accompanying schedules and statements, and to the best of my knowledge and belief it
is true, correct, and complete. (If you are claiming a refund for a year in which a joint return was filed, each spouse must sign this refund claim.)
___________________________________________
___________________________________
____________________________
Signature
Printed Name
Title
___________________________________________
___________________________________
____________________________
Daytime Phone Number
Email
Date
▼ THE SPACE BELOW IS FOR DEPARTMENT USE ONLY ▼
B & I Number of Return or Liability Number
Amount Paid
Total Refunded
Year
Interest
Interest
Interest
Paid From
Paid To
Total Amount of Refund(s)
Grand Total
_____________________________________________________
______________________
Auditor/Tax Analyst Originating Refund
Date
_____________________________________________________
______________________
____________________________________
Supervisor/Administrator
Date
Account Number
_____________________________________________________
______________________
____________________________________
Claim Number
Commissioner/Appointee
Date
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Financial