Form Lic: Pl300 - Petition For Refund For Privilege Or Store License printable pdf download

FOR OFFICE USE ONLY

LABAMA

EPARTMENT OF

EVENUE

County ___________________________

, U

& B

ALES

USINESS

IVISION

License No. _______________________

& L

EVERANCE

ICENSE

ECTION

Type Refund_______________________

P. O. Box 327550 • Montgomery, AL 36132-7550 • (334) 353-7827

State’s Part

(Less Commission)

$ ______________

Petition for Refund

County’s Part

LIC: PL300

(Less Commission)

$ ______________

05/05

for Privilege or Store License

Total

$ ______________

The undersigned petitioner requests a refund of the amount erroneously or excessively paid, as evidenced by license No. _________________________________

dated _____________________________, issued by the Issuing Agent of ______________________________________ County, which license is hereto attached

(Enclose Original License).

Explain in detail the reason for refund claim (attach additional pages if necessary).

Under penalties of perjury, I declare that the above information is true, correct, and complete to the best of my knowledge and belief.

____________________________________________________

PETITIONER’S NAME

LICENSE NUMBER

(

)

____________________________________________________

D/B/A

TELEPHONE NUMBER

____________________________________________________

PETITIONER’S SIGNATURE

PETITIONER’S TITLE

____________________________________________________________________________________________________________

MAILING ADDRESS

____________________________________________________________________________________________________________

CITY

STATE

ZIP CODE

DO NOT WRITE IN SPACE BELOW — STATE OF ALABAMA USE ONLY

I, __________________________________________________________________________, State of Alabama, hereby certify that the above petition is true and

correct and the amount as set out in the above petition was paid under the facts as herein stated, and therefore the petitioner is entitled to a refund from the State in

the amount of $__________________________________ and a refund from said County in the amount of $__________________________________.

This _________ day of _____________________, _________.

DEPARTMENT OF REVENUE

By _______________________________________________

__________________________________________________

Manager, Severance & License Tax Section

To State Comptroller/Financial Operations:

You are requested to draw your warrant on the State Treasurer in favor of _________________________________________________

__________________________, (petitioner) for $______________________________.

__________________________________________________

Manager, Severance & License Tax Section

To Board of County Commissioners or other like governing body of __________________________ County: