CITY OF PUEBLO                   _____________Claim# 
                                     CLAIM FOR REFUND 
                                      (Please Print or Type) 

NAME OF CLAIMANT ______________________________________________________  ACCOUNT# _____________ 
RESIDENCE OR BUSINESS ADDRESS ________________________________________________________________ 
                                                STREET                CITY                                          STATE/ZIP 
MAILING ADDRESS ________________________________________________________________________________ 
(IF DIFFERENT FROM ABOVE)                      STREET                 CITY                          STATE/ZIP 

PHONE# _______________________   CONTACT PERSON _______________________________________________ 
E-Mail____________________________________________________________________________________________ 
TAX PERIOD FROM                       TO                              DATES PAID                                                             

     AMOUNT OF TAX PAID 
     CORRECT AMOUNT OF TAX LIABILITY  
     AMOUNT TO BE REFUNDED  

REASON FOR CLAIM 

I/we declare, under the 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 a true, correct, and complete return made in 
good faith, for the purposes stated, pursuant to the ordinances of Pueblo and the Regulations issued under authority 
thereof. 

_________________________________________________________________________________________________ 
     NAME OF FIRM OR EMPLOYEE, IF ANY
________________________________________________________________________________________________________________________ 
     SIGNATURE OF TAXPAYER                                                                   DATE
                                     SEE INSTRUCTIONS ON REVERSE SIDE 

FOR INTERNAL USE ONLY 

(I certify that I have made an examination of the claim and facts submitted and recommend that the amount indicated herein be refunded) 

Refund Amount Rejected ___________________________ Type of Tax/Fee Refunded ___________________________ 

Total Refund Allowed ______________________________  Date  

Reasons For Actions Taken __________________________________________________________________________ 
_________________________________________________________________________________________________ 
_________________________________________________________________________________________________ 
_________________________________________________________________________________________________ 
Audited By _____________________________________  Reviewed By ______________________________________ 
Date ___________________________________________  Date ____________________________________________ 
I hereby approve the refund of ___________________, as recommended and approved for payment  

                                                       ________________________________________________ 
                                                                        Director of Finance 

                                      INSTRUCTIONS 

1. The claim must set forth in detail each ground upon which it is made, and facts sufficient to inform the Department of 
Finance of the exact basis thereof. 

2. The claim should be signed by the taxpayer, if possible.  Whenever it is necessary to have the claim executed by an 
attorney or agent, on behalf of the taxpayer, an authenticated copy of the document specifically authorizing such an 
agent, or attorney to sign the claim on behalf of the taxpayer should accompany the claim. 

3. Where the taxpayer is a corporation, the claim shall be signed with the corporate name, followed by the signature and 
title of the officer having authority to sign for the corporation. 

4. Any false statement made by applicant for Sales Tax refund is punishable on conviction by maximum fine of $300.00 or 
jail sentence of ninety days or both. 

5. Sufficient documentation must be included with the request for refund or it will delay the processing of your claim or 
cause denial of your claim. 

6. Please allow 90 days for refund claim to be processed. 

7. Please note §14-4-90(b) P.M.C. – A refund shall be made, or a credit allowed, for the tax so paid under dispute by any 
purchaser who has an exemption as  provided in this chapter.  Such refund shall be made by the Director after 
compliance with the following conditions precedent: Applications for refund must be made within sixty (60) days after 
the purchase of the goods whereon an exemption is claimed, and must be supported by the affidavit of the purchaser 
accompanied by the original paid invoice or sales receipt and certificate issued by the seller, and be made upon forms 
as  shall  be  prescribed and furnished by the Director,  which forms shall  contain  such information as the  Director 
prescribes. 

8. Mail refund claims to: 
            City of Pueblo 
            P.O. Box 1427 
            Pueblo, CO  81002