Refund Claim Form - City Of Fort Collins

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Financial Services
Sales Tax Division
nd
215 North Mason Street, 2
Floor
P.O. Box 580
Fort Collins, CO 80522
970.221.6780
970.221.6782 - fax
REFUND CLAIM FOR CITY TAXES PAID
Please refer to the instructions on the back of this form.
Name of Claimant:
Residence or Business Address:
Mailing Address:
Phone:
Email Address:
Date of Payment:
Type of Tax Paid:
Total Amount Paid $
Total Refund Requested $
Reasons for Claim:
I/we declare, under penalties of perjury, that this claim (including any accompanying schedules and statements) has
been examined by me/us, and to the best of my/our knowledge and belief is true, correct and made in good faith, for
the purpose stated.
A claim by an agent must be accompanied by power of attorney.
_____________________________________________________________________________________________
Signature of person other than taxpayer preparing claim
Date
_____________________________________________________________________________________________
Signature of Taxpayer
Date
========================================================================================
Office Use Only:
Audited by: _______________________ Approved by: __________________________
Sales Tax Manager/Financial Officer
Amount of Refund: _________________ Date: ________________________________

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