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                                          CLAIM FOR REFUND  

      Refund to be made payable to, and mailed to: 
      (If this is different from the name and address on the Department records for the accounts number(s) used, 
      provide an explanation and details specific to this refund claim.) 
      1.  Taxpayer Name                                                               2.  City Account Number 

      3.  Taxpayer DBA (if applicable)   

      4.  Mailing Address   

      5.  City                                                    6.  State           7.  Zip 

      8.  Period (mo/yr  -mo/yr) - can be combined if periods are consecutive   

      A list of transactions verifying the amounts in boxes 9 through 12 below is required on the back page, and 
      evidence for each sale must be attached. 
      9.  Purchase Price           10. Original Tax Paid      11.  Correct Tax Amount 12.  Refund Requested 
          
      13.  Reason (Explain below or on a separate sheet of paper if needed).         

      I declare under penalty of perjury, that this claim including attachments is to the best of my knowledge true and 
      correct.  I further understand that the claim and documentation may be subject to the City of Steamboat Springs 
      verification process. 
      14.  Print Taxpayer Name   

      15.  Taxpayer Signature (this line must be signed by an officer, partner, or owner of the firm claiming the refund)   

      16.  Title                                                  17.  Telephone      18.  Date 

      For City of Steamboat Springs use only  
      Comments   

For all refund claims, details for each transaction included in the refund must be listed separately below.  
Evidence such as sales receipts or invoices for verification of each transaction must also be attached.  

Purchase  Original Correct Sales Tax 
Date Description Price Sales Tax Sales Tax Refund 
(without Paid Amount Requested 
sales tax) 

Total (each total must be carried forward 
to boxes 9 through 12 on the front page)  

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