CLAIM FOR REFUND                               OR     CREDIT 
 
 State of   Louisiana Parish     of   Bossier      Bossier                                                                                        This form to   be completed by    
 City‐ Parish Sales   &   Use Tax    Division                                                                                   the applicant and filed with the    Bossier City  ‐
                                                                                                                                              Parish Sales  &   Use Tax Division    
 
 Taxpayer Account          #: 
 
                                                                                                                                 FOR OFFICE  USE  ONLY      
 Name   of Taxpayer:                                                                                                              
                                                    If taxpayer is      acorporation, enter corporation name                     Date Request Received: 
                                                     
       Represented By:                                                                                                            
                                                                         Give name and   title                                           Assigned Auditor: 
 
       Mailing Address:                                                                                                           
                                                                                                                                  
          Email Address:                                                                                                         Amount Approved for  Payment: 
                                                                                                                                  
          Phone Number:          
                                                                                                                                 $     
 
 The above  representative           declares that the following         statement    is true   and correct,   that     
 the taxpayer  is   entitled to the   refund  requested    and that      they  are not delinquent         with          
 the Bossier  City   Parish‐ Sales   & Use   Tax Division  in the payment      of any                taxes. 
 
 Nature of   Tax:                                                    Period:                                                      
                         Sales or    Use                                                                                          
                                                                                                                                 Reviewed by:  
 
 Total Amount    of   Taxes Paid:                                                  $  
 
 Corrected Amount        of   Taxes That   Were  Due:                              $                                              
                                                                                                                                 Approved by:   
 Amount Requested         to   be Refunded    or Credited:                         $                                              
                                                                                                                                  
 This claim is   for the following   reasons:                                                                                     
                                                                                                                                        Date: 
 
                     Signature of    Taxpayer                                                            Date 

Copies of   supporting documentation                            such     as original           invoices,       credit  invoices,    tax returns   or proof   of             
payment MUST accompany this                            claim       form        and     must    be             RECEIVED   by the Tax      Collector    no  later  than   3 years      
from Dec.     31     of   the year       that tax becomes                due to     be considered              a valid claim.   (LA R.S. 47:337.79)