Form Rv-F1406401 - Natural Disaster Claim For Refund Of Sales Tax
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TENNESSEE DEPARTMENT OF REVENUE
NATURAL DISASTER
CLAIM FOR REFUND OF SALES TAX
DEPARTMENTAL USE ONLY
MAIL THIS FORM AND DOCUMENTATION TO:
ATTN: NATURAL DISASTER REFUND CLAIM
CLAIM DATE ________________________
TENNESSEE DEPARTMENT OF REVENUE
ANDREW JACKSON STATE OFFICE BLDG.
ACCT NUMBER ______________________
NASHVILLE, TENNESSEE 37242
FURNISH COMPLETE DETAILS TO EXPEDITE REFUND
NAME OF CLAIMANT ______________________________________________________________ SSN_______________________
(Print or type)
SPOUSE’S NAME _________________________________________________________________ SSN_______________________
ADDRESS OF PRIMARY RESIDENCE ___________________________________________________________________________
Street address at time of disaster
___________________________________________________________________________________________________________
City
State
Zip Code
County
MAILING ADDRESS __________________________________________________________________________________________
Street or P.O. Box
City
State
Zip Code
FEMA APPLICATION NUMBER ___ ____ ____ _____ ____ ____ ____ ____ ____ FEMA DISASTER NUMBER ___ ____ ____ ____
TOTAL AMOUNT OF TAX REFUND CLAIMED
$_______________
(CANNOT EXCEED $2,500)
SCHEDULE OF QUALIFYING PURCHASES AND TAX PAID
(attach additional sheet if needed)
Dates Qualifying Item(s)
Amount of
Description of Item(s) Purchased
Purchased
Name of Retailer
Sales Tax Paid
(See instructions for definitions of qualifying items)
(Purchases must be made on or
on Item(s)
after the date of the disaster)
EXAMPLE: 06-14-2012
RETAILER NAME
LIGHT FIXTURES
$19.99
EXAMPLE: 11-15-2012
RETAILER NAME
PAINTING SUPPLIES
$17.25
EXAMPLE: 12-09-2012
RETAILER NAME
WASHER/DRYER
$70.00
EXAMPLE: 12-31-2012
RETAILER NAME
FLOORING
$250.00
I CERTIFY THAT THE FOLLOWING IS TRUE:
The primary address listed above is/was my primary residence at the time of the natural disaster,
o
The damage was caused by a natural disaster that occurred on or after January 1, 2012,
o
The damage occurred at my primary residence,
o
I received FEMA disaster assistance as a result of this natural disaster,
o
Any “major appliances” included in this claim were purchased to replace an appliance that was damaged or destroyed in this
o
natural disaster,
Any “residential building supplies” included in this claim were used in my primary residence for purposes of restoration, repair,
o
replacement, or rebuilding due to this natural disaster,
Any “residential furniture” included in this claim was used in my primary residence to replace furniture that was damaged or
o
destroyed in this disaster, and
I purchased the items included in this claim and paid the sales tax directly to the retailer or through a contractor.
o
Under the penalties of perjury, I declare that the statements made in support of this claim are true, correct, and complete to the best of
my knowledge and belief. I understand that I may be subject to civil penalty of up to $25,000 if any information on which this claim is
based is false or fraudulent.
SIGNATURE _______________________________________________
DATE _____________________________
TELEPHONE NUMBER _______________________________________
FOR OFFICE USE ONLY
CLAIM EXAMINED BY ____________________________________
DATE _________________ AMOUNT APPROVED____________________
CLASS OF TAX _________________________________________
_____________________________________________________________
DIRECTOR OR DELEGATE
RV-F1406401
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