Department of Finance                                                 City of New Orleans                                                        Bureau of Revenue 

                                                                                                       Refund Form 
 Business                                                                                               Account  
 Name:                                                                                                  Number: 
 Address:                                                                                               City/State/Zip: 

 Tax Period:                                                                                            Credit/Refund  
                                                                                                        Amount Requested: 
 Contact Name:                                                                                          Title: 

 Phone Number:                                                                                          Email Address: 

 State reason(s) for refund request: (attach info that supports your claim) 
  
Submit all information and documentation that supports your claim with this claim form.  Failure to provide required info will result in your claim 
being denied.  In accordance with Bureau of Revenue Policy a credit memorandum will be issued if your payment history indicates that the credit 
can be used within 90 days.  Please allow at least 60 days from the date your claim is approved to receive a refund check. 
 
                 I certified under the provisions of perjury that the above information is true and correct to the best of my knowledge. 
 
Signature: _________________________________________________________ Date:__________________________   
                                                                                                       For Office Use Only: 
 Recommendation: 
  
 Disposition     Amount Approved:                                                                       Disbursement Type   Credit/ 
 (Approved                                                                                              (Credit Memo/Check) Check No. 
 /Disapproved):  
 Agent Signature                                                                              Date      Manager Signature:                                                                    Date: 

Authorization: 
 Collector of Revenue                                                                      Date         Director Of Finance                                                                      Date 

 City Attorney                                                                                    Date  Chief Administrative Officer                                                      Date 

  Mail To:  City of New Orleans Department of Finance, Bureau of Revenue, Attention Enforcement Unit, 1300 Perdido St, Suite1W15, New Orleans, LA 70112