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4 NEAR FINAL DRAFT 9/13/23 4
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6 *245611* 6
7 2024 Form PCR, Political Contribution Refund Application 7
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9 Complete this form to claim a refund of contributions made to Minnesota political parties and candidates for Minnesota state offices. 9
10 Include with this form your original Form EP-3, Minnesota Political Contribution Receipt, for all your contributions made between 10
11 January 1, 2024, and December 31, 2024. DO NOT STAPLE. 11
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13 TAXPAYER’S 1ST NAME,INIT TAXPAYER’S LAST NAMEXXXXXXXXXX 999999999 13
14 Your First Name and Initial Your Last Name Your Social Security Number 14
15 SPOUSE’S 1ST NAME, INIT SPOUSE LAST NAMEXXXXXXXXXXXXXX 999999999 15
16 If a Joint Return, Spouse’s First Name and Initial Spouse’s Last Name Spouse’s Social Security Number 16
17 MAILING ADDRESSXXXXXXXXXXXXXXX Check if: New Address 99999999X Foreign Address X 17
18 Mailing Address Your Date of Birth 18
19 CITYXXXXXXXXXXXXXXXXXXXX XX 123458888 1234 99999999 19
20 City State ZIP Code Number of Forms EP-3 attached Spouse’s Date of Birth 20
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22 Place an X in one box (Married couples: See the notice below) 22
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24 X (1) Single X (2) Married, filing joint application X (3) Married, filing separate application 24
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26 You may file only one application each year. You cannot file another application for the same year or amend an application after you file it. 26
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28 1 Add all contributions you (and your spouse, if filing a joint application) made during 2024 shown on 28
29 your Form(s) EP-3 attached to this application. Enter the total . . . . .. ...... ...... ...... ..... ...... ..... .. 1 12345678 29
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31 2 If you are a married couple filing a joint application, enter $150. 31
32 If you are single, or married but filing a separate application, enter $75 .. ...... ..... ...... ...... ...... ... 2 123 32
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34 3 Enter the amount from line 1 or line 2 above, whichever is less. 34
35 This is your refund amount ... ...... ..... ....... ..... ...... ..... ..... ...... ...... ...... ..... ...... .3 12345678 35
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37 4 For direct deposit of the full refund amount on line 3, enter your bank account information. (Use an account not associated with any foreign banks.) 37
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39 Account type: 39
40 X Checking X Savings 123456789123456 123456789123456 40
41 Routing Number Account Number 41
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43 I declare that this form is correct and complete to the best of my knowledge and belief. 43
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45 11223333 1234567891 45
Your Signature Spouse’s Signature (If a joint application) Date Daytime Phone
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50 Married Couples 50
51 • You must choose to file either a joint application or separate applications; you cannot file both. 51
52 • If you file a separate application, do not enter your spouse’s name, Social Security Number, or date of birth. 52
53 Do not have your spouse sign your application. 53
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55 Mail this application no later than April 15, 2025, to: 55
56 Minnesota Department of Revenue 56
57 Political Contribution Refund 57
58 600 N. Robert St. 58
59 St. Paul, MN 55146-1800 59
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63 9995 63
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