Form Au-12 - Application For Credit Or Refund Of Sales Or Use Tax - Qualified Empire Zone Enterprise (Qeze) Page 2

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Page 2 of 2 AU-12 (12/10)
Be sure to:
• include copies of all supporting documents
(see instructions); and
• use additional sheets, if necessary. Make sure your name and ID number are on each sheet.
We can’t process applications that aren’t signed, don’t include supporting documents, or that are in any other way incomplete.
Certification: I,
, the applicant named above, or partner, officer, or other authorized representative
of such applicant, do hereby:
• make application for credit and/or refund of tax, pursuant to the New York State Tax Law; and
• certify that the above statements, and any documents provided to substantiate the credit or refund claimed, are true, complete and
correct and that no material information has been omitted; and
• certify that all of the tax for which this claim is filed has been paid, and no portion has been previously credited or refunded to the
applicant by any person required to collect tax; or, if the claim for credit or refund is made by a person required to collect tax, that
the amount claimed has previously been refunded to the appropriate purchaser; and
• certify that no amount claimed has previously been subject to a credit or refund; and
• make these statements with the knowledge that willfully providing false or fraudulent information with this document with the intent
to evade tax may constitute a felony or other crime under New York State Tax Law Article 37, punishable by a substantial fine and a
possible jail sentence; and
• understand that the Tax Department is authorized to investigate the validity of the credit or refund claimed and the accuracy of any
information provided with this claim.
Applicant’s signature
Applicant’s title
Date
/
/
Representative’s signature (
)
Representative’s ID number
Date
if any
/
/

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