Form Pcr - Political Contribution Refund Application

*185612*

2018 Form PCR, Political Contribution Refund Application

Complete this form to claim a refund of contributions made to Minnesota political parties and candidates for Minnesota state offices.

Include the original Form EP-3, Minnesota Political Contribution Receipt, for all your contributions made between January 1, 2018

and December 31, 2018 with this form. DO NOT STAPLE.

Your First Name and Initial

Last Name

Your Social Security Number

If a Joint Return, Spouse’s First Name and Initial

Spouse’s Last Name

Spouse’s Social Security Number

Mailing Address

Check if: New Address

Foreign Address

Your Date of Birth

City

State

Zip Code

Spouse’s Date of Birth

Number of Forms EP-3 attached

Place an X in one box (married couples: see the notice below):

(1) Single

(2) Married, filing joint application

(3) Married, filing separate application

You may file only one application each year. You cannot file another application for

the same year or amend an application after it has been filed.

1 Add all contributions you (and your spouse, if filing a joint application) made during 2018 shown on

the Form(s) EP-3, Minnesota Political Contribution Receipt, attached to this application. Enter the total . . . . . . . . 1

2 If you are a married couple filing a joint application, enter $100. If you are

single or married but filing a separate application, enter $50 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

3 Enter the amount from line 1 or line 2 above, whichever is less.

This is the amount of the refund you will receive . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

4 For direct deposit of the full refund amount on line 3, enter all of the following. (Use an account not associated with any foreign banks.)

Account type:

Routing number

Account number

Checking

Savings

I declare that this form is correct and complete to the best of my knowledge and belief.

Your signature

Spouse’s signature (if a joint application)

Date

Daytime phone

Married Couples