Form Pcr - Minnesota Political Contribution Refund Application - 2015
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4201561
2015 Form PCR, Political Contribution
Refund Application
Complete this form to claim a refund of contributions made between January 1 and December 31, 2015, to Minnesota political
parties and candidates for Minnesota state offi ces. Include the original Minnesota Political Contribution Receipt, Form EP-3,
for all your contributions made between January 1 and December 31, 2015 with this form. DO NOT STAPLE.
Place
Your fi rst name and initial
Last name
Social Security number
an X If a
Foreign
Address:
Spouse’s fi rst name and initial (if this is a joint return)
Last name
Spouse Social Security number
Present home address (street, apartment, route)
Date of birth
Place an X
if a new address
City
State
Zip code
Spouse date of birth
Number of Forms
EP-3 attached
Place an X in one box (married couples: see the notice below):
(1) Single
(2) Married, fi ling joint application
(3) Married, fi ling separate application
You may fi le only one application each year. You cannot fi le another application for
the same year or amend an application after it has been fi led.
1 Add all the contributions made between January 1 and December 31, 2015, shown on the Form(s)
EP-3, Minnesota Political Contribution Receipt, attached to this application and enter the total. . . . . . 1
2 If you are a married couple fi ling a joint application, enter $100. If you are
single or married but fi ling a separate application, enter $50. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
3 Enter the amount from line 1 or line 2 above, whichever is less.
This is the amount of the refund you will receive . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
4 For direct deposit of the full refund amount on line 3, enter all of the following. (Use an account not associated with any foreign
banks.)
Account type:
Routing number
Account number
Checking
Savings
I declare that this form is correct and complete to the best of my knowledge and belief.
Your signature
Spouse’s signature (if a joint application)
Date
Daytime phone
MARRIED COUPLES:
• You must choose to fi le either a joint application or separate applications;
you cannot fi le both.
• If you fi le a separate application, do not enter your spouse’s name and Social
Security number and do NOT have your spouse sign your application.
Mail this application no later than April 15, 2016, to:
Minnesota Revenue
Political Contribution Refund
St. Paul, MN 55146-1800
9995
(Rev. 12/14)
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