City of Baton Rouge – Parish of East Baton Rouge 
              Dept of Finance-Revenue Division 
              P O Box 2590                                     CLAIM FOR REFUND OR CREDIT OF TAXES PAID 
              Baton Rouge, LA 70821-2590 
              Phone 225-389-3084  Fax 225-389-5369 
              www.brla.gov/659/Taxes      
 
       EBR City-Parish                               Business 
       Account Number:                               Name:   
       Business Address: 
                            
       Contact Person:                                                Contact Telephone: 
                                                                                              
            Type of Tax:                                              Contact Email Address: 
                                                                                              
               Period(s):   
      
                                                                                          Preferred Refund Method: 
      Total Taxes Remitted 
                                                                                           
      Total Taxes Due, as amended                                                             Credit Memo 
                                                                                           
      Difference (Total Refund Requested)                                                     Refund Check 
                                                    
      This refund is claimed for the following reasons (check all that apply): 
       Mathematical error on return or supporting documents 
       Taxpayer failed to claim properly documented eligible deductions on original return (resales, returns, etc) 
       Taxpayer construction of the law contrary to the collector’s construction of the law at the time of payment 
       Error, omission, or mistake of fact of consequence to the determination of the tax liability by the taxpayer or 
       collector 
       Change made by the collector in an assessment, notice or billing issued 
       Subsequent determination that taxpayer was entitled to pay a tax at a reduced rate  
       Payment exceeded the amount on the face of the return 
       Bad debt write-off 
       Other (describe):     
        
      Include the following documents with the application: 
        •     An amended return for applicable periods  
        •     If this application for refund is for multiple months, please attach a monthly detail of taxes remitted, amended 
              taxes due, and refund amounts  
        •     All documentation needed to adequately determine that a refund is due.  This may include, but is not limited to 
              original invoices, credit invoices, original tax return, proof of payment, customer exemption certificates, and 
              monthly sales summary. 
        •     For bad debt write-offs, please supply the State’s approval letter and the corresponding federal income tax return. 
       
      If all necessary documentation is not simultaneously submitted with this application, the refund request will not be 
      considered as received and ready for review. 
      
      Under the penalty of perjury, I declare that, to the best of my knowledge, all the facts alleged above as a basis for 
      reasonable cause (including all accompanying documentation) are true, correct, and complete. 
                                                                  
      Printed Name of Applicant                                  Signature of Applicant 
                                                                  
      Title                                                      Date