City of Westminster
                                                               Claim for Refund                                     Department of Finance
                                                                                                                    Sales Tax Division
                                                            Please Type or Print Clearly
                               1) Legal Name of Business or Individual Name (Last, First):

                               2) Trade Name of Business (if any):

                               3) Mailing Address:                                                              7) Contact Person (if Business):

                               4) City:                                                 5) State:     6) Zip:   8) Phone Number:

                               E-mail Address:                                                                  9) City Account Number:

10) Amount of Claim:           $                                              11) Date(s) of Overpayment:

12) Tax Type(s):               Sales       Use                 Admissions               Accommodations          Other:____________________

13) Give a brief explanation of your claim. Attach supporting documentation such as invoices, tax returns, supporting schedules, permits, etc. If the refund is to be
mailed to an address other than the address on file with the Sales Tax Division, include an explanation of why the alternate address should be used. Attach
additional sheets if necessary.

                          Under penalty of perjury, I declare that I have examined this Claim for Refund and that it is true and correct to the best of my knowledge and belief.

Claimant
Signature                 Signature                                                                             Date

                          Printed Name                                 Title                                    Phone No.
Return completed form to:      Westminster Department of Finance   Sales Tax Division   4800 W 92nd Avenue   Westminster,CO 80031
                               (303) 658-2065   Fax: (303) 706-3923  http://www.cityofwestminster.us
                                                               CITY USE ONLY

                                                                                                  CLAIM NO.     R-
Reviewed By:                                                                                                   CASHIER VALIDATION
                          Signature                                    Date                                     (If Petty Cash)

Disposition:     Denied        Approved    Approved in Part: 

Approved By:
                          Signature                                    Date

Finance Director:
                          Signature (Required if Over $15,000)         Date

                 5300.____________.0000 Amount:

ACCOUNTS         5400.____________.0000 Amount:

                 5300.____________.0911 Amount:                                                       Petty Cash Rcvd By:_________ Date:______

                             Instructions for Claim for Refund 

General Instructions                                                     Claims may be made only for overpayment of 
                                                                         City of Westminster tax. The City  will not 
                                                                         refund taxes overpaid to the State of Colorado 
Purpose of Form                                                          or  any other county,  municipality, district, or 
                                                                         taxing jurisdiction. For example, a taxpayer 
This form is used for taxpayers to request a refund of tax    who pays sales tax to another municipality due to failure to 
overpayments remitted to the City of Westminster (“City”) or  present a Westminster building permit must seek a refund 
to a retailer  licensed and authorized to collect the same.   from that municipality. 
Pursuant to § 4-1-17 of the Westminster Municipal  Code        
(the “Code”), no tax overpayment shall be refunded unless     Line 11 – Date(s) of Overpayment. List the dates the tax 
a signed Claim for Refund  form is submitted along  with      was purportedly overpaid. Taxpayers seeking a refund of 
adequate documentation of the claim.                          disputed tax paid to a licensed Westminster retailer should 
                                                              list the date of the purchase in dispute. Taxpayers seeking 
Reminders                                                     a refund of taxes overpaid on a return should list the return 
                                                              periods covered. All other claimants should list the date 
Include supporting documentation. Documentation               such overpayment was paid to the City. 
supporting (1) that Westminster tax was, in fact, paid to the  
City or to a licensed retailer; (2) the date(s) that          Line 12 – Tax Types.    Check the appropriate boxes 
overpayment  occurred; and (3) that Westminster tax  was      indicating the tax types for which a refund is being claimed. 
not due must be submitted along  with the Claim form.         If a refund of multiple tax  types is being claimed, the 
Claims that are not adequately documented will be denied.     specific  amounts attributable to each tax type should be 
                                                              detailed on line 13. 
Claims may be barred by the Statute of Limitations.            
 A purchaser  who claims that Westminster tax  was           Line 13 – Explanation of Claim. Give a brief account of 
  erroneously paid  on  a purchase from  a licensed           the reasons for the claim. Details should include whom the 
  retailer must submit all claims on or before sixty (60)     tax was paid to, if applicable, and why the tax is not due. If 
  days from the date of such purchase.                        the overpayment  was the result of a calculation error, 
 Any claim for refund resulting from a  Notice of            describe how the error occurred. If the taxpayer is claiming 
  Overpayment must be submitted on  or before thirty          transactions or items should  be exempt under the Code, 
  (30)  days from the date of such  Notice of                 cite the applicable sections.  All relevant factual and legal 
  Overpayment.                                                claims should be  included. Also include other required 
 All other claims must be submitted on or before three       explanations such as the reason for an alternate mailing 
  years after the date of such overpayment was paid to        address or the amounts attributable to multiple tax types. 
  the City.                                                   Attach additional sheets if necessary. 
                                                               
Refunds are  not assignable. The right of any person to       Documentation –         Attach the various documents 
obtain a refund shall not be assignable.                      supporting the claim. Additional documentation may be 
                                                              requested if it is needed to complete the review. 
Signature required.  The person completing the  claim on       
behalf of the taxpayer must sign and date the form at the     Signature – After reviewing the form for accuracy, sign and 
bottom. A printed name is also required. If the taxpayer is   date the form. Print  your  name and title below  your 
not a natural person, the  title of the officer or agent      signature. Return the form to the Westminster Dep artment 
completing the form on behalf of the taxpayer must also be    of Finance along with the required documentation. 
printed on the form. Forms  without a signature  will  be      
returned and may not be considered timely filed.              Review & Determination – The review time required  will 
                                                              vary depending on the nature and scope  of the claim. If 
                                                              necessary, the claim  will  be assigned to  an auditor  who 
Specific Instructions                                         may contact  you regarding the review. If the claim is 
                                                              approved, a refund check  will be sent approximately two 
Lines 1 thru 8 – Claimant Information.  Print the legal       weeks after approval. Claims under $200 may be disbursed 
name, the trade or other name the taxpayer is known as,       immediately  by the Cashier at City Hall.  If the claim is 
and the mailing address of the organization. For claims by    denied, in full or in part, written notice of the determination 
natural persons, print the  last name followed by the first   will  be sent along  with  the payment, if any. Such 
name on line 1 and do not complete  line 2. Licensed          determination may be protested within twenty (20) days of 
taxpayers requesting that the refund  be mailed to  an        issuance. 
                                                               
address other than the address on file with the Sales Tax                                     
Division must  include an explanation  of  why the refund                                     
should be mailed to the alternate address on line 13.                                         
                                                                                              
Line 9 – City Account Number. If the taxpayer is licensed                               
with the City, list the 7 digit City account number.                      Department of Finance 
                                                                                   Sales Tax Division 
                                                                                       nd
Line 10 –  Amount  of Claim. List the claimed amount of                   4800 W 92  Avenue 
Westminster tax  overpaid in dollars and cents. Do not                    Westminster, CO 80031 
round.                                                                             (303) 658-2065