SALES TAX & LICENSING DIVISION                                                             EMAIL               penneyb@louisvilleco.gov
749 MAIN STREET                                                                            PHONE               (303) 335-4514
LOUISVILLE, CO 80027                                                                       FAX                 (303) 335-4529
www.louisvilleco.gov

                                                 CLAIM FOR REFUND

Trade (DBA) Name of Business

Taxpayer Name
Owner(s), Partner(s), or Corporation
Corporate Business Address
-Street, City, State, Zip-
Local Mailing Address (if different)
-Street, City, State, Zip-

City of Louisville SalesTax License#                              Type of Tax:             Sales
                                                                                           Use
Date Tax Paid                                                     Original Amount Paid:
(MM/DD/YY)                          ___ ___ / ___ ___ / ___ ___ 
Correct Amount:                                                   Refund Requested * :

Reason for Refund Request
(Explain in this space or on a
separate sheet of paper if 
necessary).
*All supporting documentation must be attached.

I declare under penalty of perjury that this claim, including all attachments, is true and correct to the best of my knowledge.  
I further understand that the claim and documentation are subject to the provisions and penalties contained in Ordinance 1375, 
Series 2002 as it exists or is hereafter amended.

Taxpayer Signature                  ______________________________                         Date ______________________
(This line must be signed by an officer, partner, or owner of the firm claiming the refund)
Taxpayer Name (PRINT)               ______________________________                         Phone (            )
Taxpayer Title                      ______________________________
Signature of Preparer
(if other than Taxpayer)            ______________________________                         Date ______________________
Name of Firm:                                                     Phone                    (            )