Form St11 - Capital Equipment Refund Claim
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4ST11
Capital Equipment Refund Claim
This refund must be applied for by the purchaser. Read the instructions on the back.
Name
Minnesota tax ID or Social Security number
Address
Period covered by this claim
From
Through
City
State
Zip code
Other Minnesota tax ID numbers used
during period of claim (if applicable):
Main business address in Minnesota (if different from above)
Minnesota tax ID:
Dates in effect:
to
City
State
Zip code
to
Name of person to contact about this claim
Title
Phone
E-mail
Calendar year:
This is my:
first claim
second claim for this year
Enter the refund amount you’re claiming for Minnesota and any local taxes. Attach a separate Form ST11-REF for each tax.
Minnesota
Minneapolis
St. Paul
Rochester
Mankato
$
$
$
$
$
Hennepin County
Transit Improvement
Other (specify)
Other (specify)
Other (specify)
$
$
$
$
$
Total refund claimed (add above amounts)
Describe your business activity.
I (We) declare under the penalties of criminal liability for willfully making a false claim that this claim has been exam-
ined, and, to the best of my (our) knowledge and belief, is true and complete. (A claim filed by a corporation must bear
the original signatures and titles of the officers having the authority to sign for the corporation.)
Corporations sign here
President or other principal officer
Title
Date
Phone
Non-corporations and individual taxpayers sign here
Owner, partner, or responsible party
Title
Date
Phone
Preparers sign here
Signature
Minnesota tax ID number
Date
Phone
Attach all required documentation and mail to:
If sending by email, attach all required
Minnesota Revenue
documentation and send to:
525 Lake Avenue South
salesuse.claim@state.mn.us
Suite 405
Duluth, MN 55802
Stock No. 2100112 (Rev. 10/13)
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