SALES TAX  
                                                                                                                         ST-19 

      CLAIM FOR REFUND OF COLORADO SPRINGS SALES AND/OR USE TAX 
 Utility Refunds require a Colorado Springs Utilities Consent for Release of Customer Information form for both residential 
  and commercial customer types, see links below: 
  A.) Commercial    https://www.csu.org/CSUDocuments/consentforreleaseofcustomerinfocommercial.pdf     
  B.) Residential   https://www.csu.org/CSUDocuments/consentforreleaseofcustomerinfores.pdf              
 A claim by an agent must be accompanied by a power of attorney, if necessary 
      Name of Claimant:                                                                License/Account#          

 Residence or Business Address:           
                                         Post Office Box or Street Address City. State                          Zip Code 
      Mailing Address:                                                      
  (If different from Residence/Bus Add) 
      Contact Name:                                                                                     Phone:  

                     Email:               

      Period(s)  From:                       To:   

      Items Purchased From:               

                    Address:              

 Total Price of Items Purchased:         $ 

 Amount of Sales/Use Tax Paid:           $ 

      Amount of Claim:                   $ 

      Reason for Claim:                   

I declare, under penalty of perjury, that this claim, and all accompanying schedules and statements, have been examined 
by me and to the best of my knowledge and belief are true, correct, and made in good faith, pursuant to City of Colorado 
Springs Sales and Use Tax Code and Regulations issued under authority thereof. 
 
  Authorized Representative/Title (Print):                                                                                  

 Signature of Authorized Representative:                                                                Date:               
                                                     
OFFICE USE ONLY 
                                                    
  Original Amount of Claim:  $                                                 65120-001-6110  $                           
  Amount added/(rejected):  $                                              65120-118-5901-9160028  $ 
  Total Claim Allowed/Paid:  $                                             65120-171-1300-9160028  $                       
 I Hereby Authorize the Refund of:  $                                      65120-173-1300-9160028  $ 
                                                                               45100-166-1300  $                           

      Audited By:                                                              Date:                                      
                                                                                                                           
 For Director of Finance                                                       Date:                                      
 
                           30 South Nevada Avenue, Suite 203 (80903) TEL 719-385-5903 FAX 719-385-5291 
                    Mailing Address: Post Office Box 1575, Mail Code 225 Colorado Springs, Colorado 80901-1575 
                                            Email: salestax@springsgov.com Website: coloradosprings.gov                  Revised 7/2017 

                                                                                                         SALES TAX  
                                                                                                         ST-19 

              CLAIM FOR REFUND OF COLORADO SPRINGS SALES AND/OR USE TAX 
 
INSTRUCTIONS: 
 
 1. Utility Refunds require a Colorado Springs Utilities Consent for Release of Customer Information form for both 
    residential and commercial customer types, see links below: 
    A.) Commercial    https://www.csu.org/CSUDocuments/consentforreleaseofcustomerinfocommercial.pdf     
    B.) Residential   https://www.csu.org/CSUDocuments/consentforreleaseofcustomerinfores.pdf 
     
 2. The claim must set forth in detail each ground upon which it is made, and facts sufficient to inform the Director of 
    Finance of the exact basis thereof. 

 3. 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. 

 4. 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. 

 5. Any false statement made by the applicant for Sales/Use Tax Refund is punishable on conviction by a fine not 
    more than $500.00 or a sentence not exceeding three (3) months of both. 

 6. Please direct all questions to (719) 385-5903. 

 7. Appropriate documentation MUST BE included with Request for Refund or it will delay the processing of your 
    claim. 

                      30 South Nevada Avenue, Suite 203 (80903) TEL 719-385-5903 FAX 719-385-5291 
              Mailing Address: Post Office Box 1575, Mail Code 225 Colorado Springs, Colorado 80901-1575 
                      Email: salestax@springsgov.com Website: coloradosprings.gov