CLAIM FOR REFUND OF  AXES T                                    AIDP    
                                                      
                           City of Baton Rouge/Parish of East Baton Rouge 
                                         Department of Finance – Revenue Division 
                                                     PO Box 2590 
                                         Baton Rouge, LA  70821-2590 
                                                     (225) 389-3084 
 
Taxpayer Name:                        

Tax Account Number:                   

Business Address:                     

Business Phone:                       

Contact Person:                       

Title:                                

E-Mail Address:                       
 
Type of Tax:                                         Period(s):                        
                                                                                              (Month and Year) 
 
                                                                                               Preferred refund method: 
1.  Taxes remitted:        $                                                                    
                                                                                                Credit Memo 
2.  Taxes due, as amended: $                                                                    
                                                                                                Refund Check 
3. Refund requested:       $                        
 
Providing appropriate documentation for refund requests will expedite the refund claim.  For example, original invoice, credit 
invoice, original tax return, proof of payment.  For bad debt write offs, please supply the state’s approval letter and the 
corresponding federal income tax return. 
 
This refund is claimed for the following reasons: 

Signature of Taxpayer:                                                       Date Prepared:             
 
                This form must be notarized if the claim is greater than $1,500 
 
Sworn to and subscribed before me this _______ day of _________________________, 20_____. 
 
                                                     Taxpayer:   
(Signature of Notary Administering Oath)                                    (Name and Title) 
 
The above deponent, being duly sworn, deposes and says that the                              For Office Use Only 
following statement is true and correct, that he is entitled to the refund    Date Received:                                    
requested and that he is not delinquent with this City or Parish in the 
payment of Sales Tax, Use Tax, Hotel-Motel Tax, or Occupational               Refund Project:                                   
License Tax.                                                                                                                    
                                                                                                               Revised 4/2010