Form 2004-6 - Arkansas - Claim For Refund Page 2
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5SECTION 1 – CLAIM INFORMATION (To Be Used by all Claimants)
PLEASE PRINT OR TYPE
Claimant’s Name
Federal I.D. Number (FEIN)
Address
Social Security Number
City
State
Zip
Claimant’s Sales/Use Tax
Permit
Telephone Number
Best time to Call
(Weekday, Daytime
Area Code
Hours)
(
)
-
This refund is for Sales/Use tax paid during the period
__________________ to ___________________
INDICATE THE TOTAL AMOUNT OF REFUND YOU ARE REQUESTING
$_________________
Under penalties of law, I declare that the amount of sales or use tax for
which I am submitting this claim for refund has NOT been refunded or
credited to me by the Department or the seller to whom the tax was
previously paid. I will immediately send payment for any such duplicate
refund to the Arkansas Department of Finance & Administration; PO Box
1272, Little Rock, AR 72203-1272.
Print Your Name
Title
Signature of Claimant or
Date
Authorized Representative
If your claim results from a vendor assignment and includes a refund of
sales/use tax paid to more than one vendor, you must attach a separate
Section 2 and a separate Section 3 for each vendor and summarize your
total refund claim in Section 1. Each Separate vendor must complete
Column 12 of Section 2 and Section 3.
Please Mail your Request for Refund to:
Arkansas Department of Finance and Administration
Sales Tax Refund Request
P.O. Box 8054
Room 1340
Little Rock, Arkansas 72203-8054
Questions:
Telephone: 501-682-7130
Fax: 501-682-7667
Website:
Form 2004-6 2/07
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