FOR OFFICE USE ONLY
                                                                                                      Date Needed: /     /
                                                                                                  Charge Acct #: 010-00-000-445-009
                                                                                                  Payment Instructions:
                                   7887 East 60th Avenue                                          Return check to: ____________
                                   Commerce City, Colorado 80022                                  Mail check:  □
                                   (303) 289-3628 Phone                                           Return paperwork to Joy
                                   (303) 289-3661 Fax                                             Logos vendor # : 
                                   www.c3gov.com

                                       Tax  Division

                                       Claim for Refund
                                       (Please Type or Print Clearly)

1. Account Number:
   (Account or Building Permit Number for which refund is claimed)
2. Name of Claimant:
3. Mailing Address:
4. City:                                                                    State:                     Zip:
5. Contact Name:                                                            Phone Number:

The undersigned certifies that this statement is made on behalf of himself or the taxpayer named, that the fact given below are true 
and complete, and avers that the claim should be allowed for the reasons stated below.
   A. Dates of Payment:
   B. Amount of Tax Paid:                                                                              $
   C. Correct Amount of Tax Liability:                                                                 $
   D. Amount to be Refunded:                                                                           $
   E. Reasons for Claim (Required):

Claim for refund of a specific tax must be made within the time limits and be supported by the required documents all in accord with 
the provisions of the particular ordinance relating to such tax.

Signature of Claimant                  Date                                 Name of Firm

                                       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.

Amount Claimed:                  $                                          Amount of Claim Rejected: $
Examined By:                                                                Total Refund Allowed:     $
I hereby authorize the refund of $                                 as recommended in the report of the examining officer.

                                                                                                           Finance Director
                                                                  Signature                                Title

                                                                  Date

Claim For Refund                                                                                                   Update: 11/2/2016