of                          

                                                                                                                                  Purchased
                                                                                                      Description
                                                                                                                 Property/Services
                                                                                                                                                                                            
                                                                                                                  of
                                                                                                                                                                                                   Tax)

                                                                                                                 Location                                                                          Use
                                                                                                                                  Vendor/Seller                                                    &
                                                                                                                                   
                                                                  to
                                                                                                      Tax        Rate             Paid                                                            (Sales
               REFUNDS     REFUND                                                                      
                                                                                                       of                          
                           TO
               TAX                                                                                                Tax

                                                                                                                 Use              Claimed
               USE                                                                                    Amount                                                                                
               &                                                                                                                   
                           SUBJECT                                :                                    of
                                                                                                                  Tax
               SALES
               –                         PERIOD                                                       Amount     Sales            Claimed
                                                                                                                                                                                                   
                                                                                                                 of                
                                                                                                                  
               ZONES
                           TRANSACTIONS                                                               Taxable                     Invoice
                                                                                                                 Amount                                                                     
                           OF                                                                                                                                                                     Requested
                                                                                                                                                                                                   
               ENTERPRISE                                                                                                                                                                         Refund
                                                                                                                 Invoice          Number                                                           
                                                                                                                                                                                            
              URBAN       SPREADSHEET                                                                                                                                                             Total

                                                                                                                                   Vendor/Seller
                                                                                                                                   of
        02/12)

                                                                                                                                  Name                                                      
        (Rev.
       ‐1                                                                                                                          
                                                                                                      IP         or               TP                                                        
       ‐UEZ
                                                                                                                                   
       ‐3730                                                                                      #:                              Date
       A                                TAXPAYER:                                                ID