Proud member of LATA 
                                                    
  Ascension Parish Sales and Use Tax Authority 
                                  P. O. Box 1718 
                                  Gonzales, LA 70707 
                                                     
                   Claim for Refund of Taxes Paid 
  
 Make separate claim for each overpayment of tax and for each period 
  
 Name of taxpayer ______________________________________________________________ 
  
 Address_______________________________________________________________________ 
  
 City, State, Zip  ________________________________________________________________ 
  
 Account Number  _______________________________________________________________ 
  
 Check type of tax:       Sales Tax _____           OLT or Insurance Premium _____ 
            
                      Liquor Permit _____          Occupancy Tax _____ 
  
 Period of overpayment:__________________________________________________________ 
  
 Contact Person  ________________________________________________________________ 
  
 Email of Contact Person  _________________________________________________________ 
  
 Telephone  ___________________________ Ext___                   Fax______________________ 
  
 Total remitted for the period           $______________________________ 
 
Amount claimed to be due as amended:    $______________________________ 
 
Difference (refund requested):                          $_____________________________ 
  
 This refund is claimed for the following reasons: 
  
 Providing appropriate documentation for refund requests will expedite the refund claim.  For 
 example:  original invoice, credit invoice, original tax return, and proof of payment.  For bad debt 
 write-offs, please supply the states approval letter. 
 *************************************************************************************************************** 
 FOR OFFICE USE ONLY:  Total Approved for Payment:  $______________________________ 
 
Date: _______________           Auditor:  ____________________________________________ 
 
Date:  _______________          Administrator:  _______________________________________ 

 Rev 09/04                                                           Claim for Refund of Taxes Paid.doc