Form 2004-6 - Arkansas - Claim For Refund Page 3
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5Specific Instructions
Claim for Refund
Section 2
This form is to be submitted in electronic format (Excel) unless the listing is less than
25 lines. If listing is less than 25 lines, the form may be submitted in paper format.
This form can be located at:
If “paperless” invoice system exists between vendor and claimant, documents
containing the information as requested in Columns 1 - 12 may be substituted.
Column 1: The date that appears on the invoice.
Column 2: Vendor name
Column 3: Invoice number that appears on the invoice.
Column 4: A brief description of the goods and/or services listed on the invoice.
Column 5: A detailed explanation of the item/service and what exemption is being
claimed. Reference to an Arkansas code section or rule is not a sufficient
explanation. The explanation should include sufficient factual information to fully
describe the basis for the refund claim. If more room is needed, attach a separate
sheet containing the explanation.
Column 6: The amount of the purchase for which a refund is being requested. If a
refund is being requested on only a portion of the invoice, then only that portion
should be listed here. If a discount was taken when the invoice was paid, only the
amount actually paid may be refunded.
Column 7: The amount of state tax applicable to column 6.
Column 8: The amount of county tax (if any) applicable to column 6.
Column 9: The amount of city tax (if any) applicable to column 6.
Column 10: County Name (if applicable)
Column 11: City Name (if applicable)
Column 12: Month and Year of excise tax report on which tax was reported and paid.
This column is to be completed by the purchaser if the request is for tax paid directly
by the purchaser to the state. This column is to be completed by the vendor if the
refund claim is being filed by the vendor or by the purchaser following an assignment
of the refund claim by the vendor.
Refund Requests containing incomplete information or missing invoices will
be denied and returned to Claimant.
Form 2004-6 2/07
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