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Rev. 3/18
For State Use Only ST AR
Overrides: Name Y N Address Y N Sales/Use Tax
Application for Refund
Sales Tax / Consumer Sales Tax / Vendor Use Tax
The following information refers to the person/entity submitting the application for refund of tax claimed to have been erroneously paid to the state of
Ohio/Clerk of Courts.
FEIN/SSN (do not use dashes) Sales or use tax vendor's license number (if applicable)
Name of applicant (if business, print name as registered with the Internal Revenue Service)
Mailing address
City State ZIP code
Telephone Fax
E-mail
Requested refund amount Time period covered by the refund request (MM/DD/YY)
$ MMDDYY MMDDYY
State full and complete reasons for the above claim. You must include supporting documentation.
SIGN HERE (REQUIRED)
I declare under penalty of perjury that I am the taxpayer or the taxpayer’s authorized agent having knowledge of the relevant facts in
this matter to fi le this refund application.
Signature Date (MM/DD/YY)
Name Title
Taxpayer representative: The taxpayer will be represented in the matter by the following individual. Include a Declaration of Tax
Representative (Ohio form TBOR 1), which can be found on the department’s Web site at tax.ohio.gov.
First name M.I. Last name
Telephone Title
E-mailE-mail
FOR OFFICE USE ONLFOR OFFICE USE ONLYY
Examiner Examiner Date Date Amount recommendedAmount recommended
Reviewer Reviewer Date Date Manager Manager DateDate
Claimed Claimed Inc/red Inc/red DeallocationDeallocation
Xfer tax Xfer tax Xfer int Xfer int TTotal approvedotal approved
Int to txpr Int to txpr Net to Net to TP TP Txpr ckTxpr ck
Please send this application and supporting documentation to: Ohio Department of Taxation,
Audit Division – SUT REF, PO Box 183050, Columbus, OH 43218-3050.
