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