CITY OF MONTROSE 
                                                             FINANCE DEPARTMENT
                                                               P.O. Box 790 
                                                             Montrose, CO 81402 
 
Type or Print:  
Name of Person/Business/Organization requesting refund:________________________________________ 
Mailing Address                                              Physical Address
   
Name of Person/Business/Organization who collected and remitted sales tax to the City of Montrose: 
Name __________________________________                      City Sales Tax Account #  ______________________ 
Mailing address   _________________________                  Physical Address _____________________________ 

                _________________________                                    _____________________________
 
Refund should be payable to:  Name  ______________________________________________________                               
                         Address    ______________________________________________________
 
The undersigned certifies that this statement is made on behalf of himself or the taxpayer named, that the facts given 
below are true and complete, and avers that the claim should be allowed for the reasons stated below. 
 
 1.  Date(s) of transaction(s)  
 2. Period(s) Filed  
 3.  Character or Kind of Tax  
 4.  Amount of Tax Paid  
 5.  Correct Amount of Tax Liability  
 6.  Amount to be Refunded  
Reason for Claim: 
 
                         (Attach letter size sheets if space is not sufficient) 
 Claims for disputed City of Montrose Sales or Use Tax Code 5-15-9, must be supported by affidavit of 
 purchaser accompanied by original paid invoice or sales receipt and certified by the seller. 
 
I/We declare under the penalties of perjury, that this claim (including any accompanying schedules and statements) has been 
examined by me/us, and to the best of my knowledge and belief is a true, correct, and complete return mad in good faith, for the 
purposes stated pursuant to the ordinances of the City of Montrose and the Regulations issued under authority thereof.  
 
(Signature of person, other than taxpayer, preparing return)      (Signature of Taxpayer) 

 (Name of firm or employer, if any)                               (Date) 

                                 INSTRUCTIONS 

1.  The claim must set forth in detail each ground upon which it is made, and facts sufficient to 
  inform the City of Montrose Finance Department of the exact basis thereof. 
2.  The claim should be signed by the taxpayer, if possible. Whenever it is necessary to have the 
  claim executed by an attorney or agent, on behalf of the taxpayer, an authenticated copy of 
  the document specifically authorizing such an agent, or attorney, to sign the claim on behalf 
  of the taxpayer should accompany the claim. 
3.  Where the taxpayer is a corporation, the claim shall be signed with the corporate name, 
  followed by the signature and title of the officer having authority to sign for the corporation. 
4.  Any false statement made by an applicant for Sales/Use Tax refund is punishable in 
  accordance with the City ordinance. 
 
                             For Finance Department Use Only 
                                         
Amount Claimed $ 
Amount of Claim Rejected $ 
Amount of Tax Allowed $ 
Total Refund Allowed $ 
 
Reason(s) for Action Taken:  
 
I certify that I have made an examination of the claim and facts submitted by the taxpayer and 
recommend that the amount herein be:   Refunded                    Denied
 
Audited by:                                   Sales Tax Auditor    Date ____________ 
 
Reviewed by:                                  Sales Tax Accountant  Date ____________ 
 
As recommended in the report by the Examining Officer, I hereby approve/deny the Sales/Use 
Tax Refund of  
 
$ 
 
Refund is Approved                             Refund is Denied 
  
By:                                    Finance Director      Date
  
Refund made by:     Crediting Account#                       Issued
 
   Check #      Issued 
 
Taxpayer notified of Denial on                               By: