Department Revised: July 2014  Refund:
MEMOS Tax  for 
 
 Sales  ONLY
to 
 
CREDIT  Board  USE $ Approved
 
 School Director of Sales Tax 
 BREAKDOWN
 
 Parish OFFICE Amount $

 FOR
 
 Calcasieu
 the cer: 
INCLUDING for AREA ffi JURISDICTIONAL on(s):
 
THIS
SB LED LC 
PAID  Collector  Jurisdic SB SAL LED2 PJ#1 PJ4A SUL DQ VIN WL 
 LCEMP IOWA TOTAL Date 
 the SB#3 (MB) 

 with Reviewing Tax O Total Amount Requested for Refund: Taxing
Date Request Received: 
TAXES fi led Interest to be computed Total Approved for Payment: Refund Check(s) Mailed: 
 
 and   
OF
  is   
  
 any
  of   
 by Applicant delinquent , 
 
 statement   
 not
REFUND on name 
   is  payment  
 completed he  
 
  the  
 to be  following in
FOR  that  
  is the   
tle  
  and Signature of Taxpayer 
 form that  Board
on, enter corpora    Submit copies of returns and/or credit memos associated with refund period(s)
This  
day of 
CLAIM  says NOTE:
 School                      
 Give name and  and  requested Period: $ $ $
 
  Parish
 ‐4281
 refund
Street  deposes 
6th 2050‐ 217 If Taxpayer is a corpora  the
 
Department (337) to Calcasieu 
2439 70602  Fax  sworn,
 Tax   tled the 
 LA  
 Use 2050 duly en and  
‐4280  
 is Sales or Use 
and Charles,  217  being he taxes.
 Drawer   
  
Sales PO Lake (337) www.calcasieusalestax.org  that Louisiana 
 BY:  of  local

  TAXPAYER: ADDRESS:  deponent,  and
 #:  correct, State 
 OF  state
 above  and  the
Signature of Notary administering oath 

Account NAME REPRESENTED MAILING The true with other Nature of Tax: Total Amount of Taxes Paid: Corrected Amount of Taxes That Were Due: Amount Requested to be Refunded: This refund is claimed for the following reasons: Sworn to and subscribed before me this: My Notary commission expires: