Form 2004-6 - Arkansas - Claim For Refund Page 4

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Section 2 (To be filled out by Purchaser and/or Vendor)
Claimant's Name:
SCHEDULE OF PURCHASES
Col 1
Col 2
Col 3
Col 4
Col 5
Col 6
Col 7
Col 8
Col 9
Col 10
Col 11
Col 12
Date Tax
How used/exemption claimed
Remitted
Invoice
Invoice
(Note: A reference to a
Price
Ark State
to State
Date
Vendor Name
Number
Description
statute/rule will not suffice)
Before Tax
Tax
County Tax
City Tax
County Name
City Name
(MM/YY)
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
21.00
21.00
21.00
21.00
Totals
63.00
Total Tax Refund Requested (Col 7 + Col 8 + Col 9)
Form 2004-6 2/07

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