Form St11p - Special Purchase Refund Claim

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ST11P
Special Purchase Refund Claim
Use this form only for the types of claims listed below.
These types of refunds must be applied for by the purchaser. Read the instructions on the back.
Name
Minnesota tax ID or Social Security number
Address
Period covered by this claim
From
Through
Check type of claim (see instructions)
City
State
Zip code
Construction exemptions
for special projects under M.S. 297A.71:
Main business address in Minnesota (if different from above)
JOBZ
Qualified Data Center
City
State
Zip code
Other:
Name of person to contact about this claim
Phone
E-mail
Calendar year:
This is my:
First claim
second claim for this year
Enter the refund amount you’re claiming for Minnesota and any local taxes.
Minnesota
Minneapolis
St. Paul
Rochester
Mankato
$
$
$
$
$
Other
Other
Other
Other
Other
$
$
$
$
$
Total refund claimed (add above amounts)
If you have additional information to support your claim, include it here. Attach additional sheets if necessary.
I (We) declare under the penalties of criminal liability for willfully making a false claim that this claim has been exam-
ined, and, to the best of my (our) knowledge and belief, is true and complete. (A claim filed by a corporation must bear
the original signatures and titles of the officers having the authority to sign for the corporation.)
Corporations sign here
President or other principal officer
Title
Date
Phone
Non-corporations and individual taxpayers sign here
Owner, partner, or responsible party
Title
Date
Phone
Preparers sign here
Signature
Minnesota tax ID number
Date
Phone
Check here if Form REV184, Power of Attorney, is attached.
Attach all required documentation and mail to: Minnesota Revenue, 525 Lake Avenue South, Suite 405, Duluth, MN
55802 Questions? Email us at salesuse.claim@state.mn.us. Call 651-296-6181. Alternative formats available upon
request.
(Rev 10/13)

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