FINANCE DEPARTMENT                                         CLAIM FORM FOR 
                                               SALES TAX DIVISION 
                                                                                                           REFUND
                     911 10TH ST.   GOLDEN, CO 80401        •   TEL:  303-384-8024 

Claimant Name  

City Account Number  

Mailing Address  

City                                                                     State                    Zip  

Contact Name  

Phone Number  (           )                     Email  

TYPE OF REFUND  (Please check one) 

          q Sales Tax               q Consumer Use Tax          q Building Use Tax 

Amount of Refund Requested        $ 

Explanation of Claim (Please attach relevant documentation) 

By my signature below, I declare, under the penalty of perjury, that the statements made herein are to the best of my knowledge true  
and correct. 

Signature of Claimant   

Title                                                                    Date  

 (FOR CITY USE ONLY) 
 Auditor                                                                        A/P Vendor Number                     99998  

 Amount Denied     $                                                            Amount Approved         $ 

 Reason/Comments                                                                Account Number   

                                                                                  Authorization   

                                                                                Date Approved   

                                                                                Date Mailed   
 ARN #                               A/P                           ST                             Check #  

CRF 11/10