City and County of Broomfield                                              Sales Tax Administration 
 
                       ONE DESCOMBES DRIVE                       BROOMFIELD, CO 80020                            303-464-5811 
                                                                                             Email: salestax@broomfield.org 
 
                       REFUND CLAIM:                             FORSALESTAXPAID 
 
      1)   This claim form must be accompanied by supporting documentation of sales tax paid to a BROQMFIELD 
            vendor. Include copies of sales invoices, receipts.  building permits,etc., or any other documentation that 
            proves the amount of tax paid. 
      2)    If this claim is for sales tax paid, where you have previously paid Local Use Tax on a     building permit, we 
            will limit the refund to the amount of Use Tax paid and receipted on the permit  We do not refund State or 
            RTD sales tax, as those taxes are not ''pre-paid" on the building permit. 
      3)    Claims for local sales tax paid to other jurisdictions will not be accepted. You must file with the other 
           jurisdictions. 
      4)   This claim form must be signed and dated by the taxpayer. If the taxpayer is a corporation, the claim must 
            be signed with the corporation name, followed by the signature and title of the officer having the authority 
            to sign for the corporation. Incomplete forms will not be processed. 
 
 1) 
      Taxpayer Name 
 
 2) 
      Taxpayer DBA (If applicable) 
 
 3)                                                                                
      Mailing Address 
 
 4)                                                 5)                         6)                 _____ 
      City                                                State                       Zip code
 
 7)                                                 8)                         9)  __________________
       Original Amount Paid                            Correct Amount                 Refund Requested 
 
 10)  Reason for claim: Supporting documentation must be attached: 
 
 11) I declare under penalty of perjury in the second degree that this claim, including all attachments, is true and 
 correct to the best of my knowledge: 
 
 12)                                                             13)                                                    
        Signature                             Date                      Signature of Preparer (if other than taxpayer) 
 
 14)                                                             15)                                                     
        Title                                                           Telephone #                    Fax#    
 
 16)                                                              17) 
       Name of Firm:                                                    Telephone  #                   Fax# 
 
 18)                                                              19) 
        Email address                                                   Date