City  
                                   of 
                                   Boulder 
                                   Sales/Use Tax Division 
      _______________________________________________________________ 

                        CLAIM FOR REFUND OF BOULDER TAX 

      Taxpayer’s Name __________________________________________________ 
      Business Street Address _____________________________________________ 
      City_____________________________ State ______ Zip Code _____________ 
      Phone # ______________ Contact Person _______________________________ 
      City Sales Tax # ___________ Date return was filed/tax paid ________________ 
      Reporting period ___________ to ___________ Type of Tax ________________ 

      Reason for Refund 

      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/our knowledge and belief is true, correct and complete for the purpose stated, 
      pursuant to the City of Boulder Tax Cod and Regulations issued under the authority thereof. 

      _____________________________                  ___________  ____________________________ 
      Signature of Claimant                          Date                                Title 

                                                  For City Use Only 
      I certify that I have made an examination of the claim and facts 
      submitted and recommend that the amount indicated herein be refunded                   Refund Requested                 $___________ 

      _________________________  _________________                                           Amount Rejected                  $___________ 
      Examined By                               Date                                         Amount Increased                 $___________ 
                                                                                             Total Refund Amount              $___________ 
      Approved By                               Date 

         White – Scanning                       Yellow – Tax Office                                               Pink – Auditor 

 1136 Alpine Avenue,1777Boulder,BROADWAY     CO 80304            P.O. BOX 791    P.O. BOXBOULDER,791 Boulder,CO  80306     CO 80306                303-441-3921303/441-3050