Form St11 -Ul - Utilities Sales Tax Refund Claim
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2ST11-UL
Utilities Sales Tax Refund Claim
This claim must be filed by the utilities service provider requesting an adjustment to taxable sales.
Instructions are on the back of this form.
Name
Minnesota tax ID number
Address
Period covered by this claim
From
Through
City
State
Zip code
Main business address in Minnesota (if different from above)
City
State
Zip code
Name of person to contact about this claim
Title
Phone
E-mail
Enter the refund amount you are claiming for Minnesota sales tax and any local sales taxes.
Minnesota
Minneapolis
St. Paul
Rochester
Mankato
$
$
$
$
$
Hennepin County
Transit Improvement
Duluth
St. Cloud area
Other (specify)
$
$
$
$
$
Other (specify)
Other (specify)
Other (specify)
Other (specify)
Other (specify)
$
$
$
$
$
Total refund claimed (add above amounts)
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 signature and title of the officer having the authority to sign for the corporation.)
Corporations sign here
President or other principal officer
Title
Date
Phone
Non-corporations 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 documentation and mail to:
Claims Unit, Minnesota Revenue, 525 Lake Avenue South, Suite 405, Duluth, MN 55802
Or email claim and documentation to: salesuse.claim@state.mn.us
(10/13)
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