Form 2004-6 - Arkansas - Claim For Refund Page 5
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5Arkansas
Vendor Assignment of Right to Refund
Arkansas State Taxes, County Taxes and City Taxes
SECTION 3 – VENDOR (Seller) INSTRUCTIONS
This sections is to be completed by the Vendor
(Vendor – Please retain a copy for your records)
On the previous pages of this claim your customer has entered information
concerning transactions for which they are claiming a refund of Sales/Use tax from
the Arkansas Department of Finance & Administration. Please review Section 2. If
you have not previously received or requested a refund of the sales or use tax listed
on the schedule, and have not credited your customer for the tax, complete Column
12 of Section 2 and the information boxes below. Be sure to include the signature
of an authorized representative of your company. Return Sections 2 and 3 to your
customer. The statement below will be submitted to the Department of Finance &
Administration along with your customer’s claim for refund.
Seller’s Legal Name
Seller’s Arkansas Sales/Use Tax Permit Number
Seller’s Business/Trade Name
Seller’s Business Address
Telephone Number
Area Code
(
)
-
Buyer’s Name
I declare under penalties of law that I have read and examined this document and
attest to the fact that the items listed in the Schedule of Purchases in Section 2
were sold by me and that the proper sales/use tax and, where applicable, county
and city tax, was charged, reported and remitted to the Arkansas Department of
Finance & Administration. I, (the seller), have not requested a refund, taken credit
on any sales/use tax return, and have not given the buyer credit for any sales/use
tax listed on the Schedule of Purchases in Section 2 (Columns 7-9). I am
authorized to sign this document.
I further declare that I will not request a refund of tax for any other sales to this
customer for any periods applicable to this claim, as set forth in Section 1.
Print Your Name
Title
Signature (Seller)
Date
Form 2004-6 2/07
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