Financial Operations 
                                                                              250 North 5th Street 
                                                                         Grand Junction, CO 81501 
                                                                    (970) 244-1536   Fax (970) 256-4078 
                         
                        CITY CLAIM FOR TAX REFUND (SALES/USE) 
 
NAME OF TAXPAYER:                                                                                           
                                                                     
MAILING ADDRESS:                                                     TELEPHONE:                             
                                                                     
CITY:                                                     STATE:       ZIP:                                 
 
A.   TAX INFORMATION 
     1.    Kind of Tax:                 To Whom Paid:                                                       
     2.    Date Paid:                   Amount of Tax Paid:                                                 
     3.    Correct Amount of Tax Liability:                        $                                        
     4.    Amount Requested to Be Refunded:                        $                                        
     (All claims for refund must be accompanied by supporting documentation verifying the information stated 
     above.) 
 
B.   IF YOU ARE LICENSED WITH THE CITY: 
     1.    City License Account Number:                                                                     
     2.    Date Return was filed:                         Tax Period:                                       
 
C.   REASON FOR CLAIM/ ADDITIONAL INFORMATION 
                                                                                                            
I hereby certify that I have examined this claim (including any accompanying documentation) and that it is to the 
best of my knowledge and belief a true and complete claim made in good faith for the purpose stated above. 
 
Taxpayer                                                 Taxpayer 
Name:                                                    Signature:                                         
                  (Please print) 
Taxpayer Title:                                          Date:                                              

Prepared By:                                             Telephone:                                         
                  (Please print)                         
                 (Claim for Refund must be signed by individual taxpayer or company official.) 
 
                                        << Office Use >> 
                                                         
Amount Claimed:         $                                           Prepared:                               
Amount of Claim Denied  $                                           Reviewed:                               
Amount of Claim Approved   $                                        Approved:                               
Comments:                                                                                                   

Form #GJ900 (9/2013)