Form St11 -Pur - Purchaser Sales Tax Refund Claim And Schedule
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4ST11-PUR
Purchaser Sales Tax Refund Claim
The claimed refund must be for more than $500 in tax. Read the instructions on the back.
Name
Minnesota tax ID number
Address
Period covered by this claim
From
Through
City
State
Zip code
Other Minnesota tax ID numbers used during
period of claim (if applicable):
Minnesota tax ID:
Dates in effect:
Main business address in Minnesota (if different from above)
to
City
State
Zip code
to
Name of person to contact about this claim
Title
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.
Minneapolis
St. Paul
Rochester
Mankato
Minnesota
$
$
$
$
$
Hennepin County
Transit Improvement
Other (specify)
Other (specify)
Other (specify)
$
$
$
$
$
Total refund claimed (add above amounts)
Describe your business and the reason you are filing this claim. Include statute references if applicable.
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. I (We) will not pursue a refund for items
on this claim through the vendor(s). (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 individuals sign here
Owner, partner, or responsible party
Title
Date
Phone
Preparers sign here
Signature
Minnesota tax ID number
Date
Phone
Attach all required documentation and mail to:
If sending by email, attach all required
Minnesota Revenue
documentation and send to:
525 Lake Avenue South
salesuse.claim@state.mn.us
Suite 405
Duluth, MN 55802
Stock No. 2100114 (Rev. 10/13)
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