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
1Indiana Department of Revenue
Form
GA-110L
Claim for Refund
Mail to: 100 N Senate Ave. Rm N203 MS#105
State Form 615
R2 / 8-08
Indianapolis, IN 46204-2253
Name of Taxpayer
Taxpayer Identifi cation Number:
Address:
Federal Identifi cation Number:
City:
State:
Zip:
Social Security Number:
□
□
□
□
Check Tax Type
Financial Institutions
IFTA
Oil Inspection
Underground Storage
□
□
□
□
□
Cigarette
Food & Beverage
Individual
Oversize/Overweight
Withholding
□
□
□
□
□
Corporation
Gaming Excise
IRP
Prepaid Sales on Gasoline
Other ___________________
□
□
□
□
County Innkeepers
Gasoline
Motor Carrier
Sales & Use
□
□
□
□
Fiduciary
Hazardous Chemical
MVR-Excise
Special Fuel
A complete explanation is required as to why the refund is due. Attach ALL documentary evidence to support your claim. Failure to attach all documen-
tation with the claim will result in the claim being returned or denied. Please allow 45 days for processing before contacting the Department regarding
the status of your claim. A Power of Attorney (POA-1) form must be completed and attached authorizing the Department to discuss your claim and
specifi c tax type with anyone other than the taxpayer.
Year or Period Ending
Requested Refund
Date(s) of Tax
Year or Period Ending
Requested Refund
Date(s) of Tax
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 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 fi led, each spouse must sign this refund claim.)
___________________________________________
___________________________________
____________________________
Signature
Printed Name
Title
___________________________________________
_______________
Daytime Phone Number
Date
▼ THE SPACE BELOW IS FOR DEPARTMENT USE ONLY ▼
Year
B & I Number of Return or Liability Number
Amount Paid
Interest
Interest
Interest
Total Refunded
Paid From:
Paid To:
Total Amount of Refund
_____________________________________________________
______________________
____________________________________
Auditor/Tax Analyst Originating Refund
Date
Account Number
Claim Number:
_____________________________________________________
______________________
Supervisor/Administrator
Date
____________________________________
_____________________________________________________
______________________
Commissioner/Appointee
Date
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Financial