City of Leeds 
                                         1040 Park Drive 
                                         Leeds, AL 35094 
                               Phone: 205-699-2585 
                                         Fax: 205-699-6558 
                                                      
                           Tax Refund Request

                           Type of Tax:
                               Joint                        Individual
      Note: Separate requests are required for each type of tax. 

The undersigned hereby makes application for refund of ($__________________) 
_________________________________________________Dollars. Taxes paid by said 
undersigned to the City of Leeds for the period(s)________________________________, 
which amount was erroneously paid or paid in excess of the amount due or was paid  
through mistake of fact or law.

Explain in detail the reasons for refund claim ( attach additional pages if necessary):

Signatures:  A joint petition must bear the signatures of both the seller and the  
consumer-purchaser. If a petitioner is an individual, the individual must sign. If a petitioner 
is a business organization (i.e corporation, partnership, LLC), an authorized representative  
must sign.

Petitioner's Name (Seller)                            Petitioner's Name (Consumer-Purchaser)

Account Number                     Telephone Number   Account Number                     Telephone Number

Petitioner's Signature/Title                          Petitioner's Signature/Title

Petitioner's Email Address                            Petitioner's Email Address

Petitioner's Mailing Address                          Petitioner's Mailing Address

 City                  State         Zip               City                       State       Zip

Date Signed                                           Date Signed