Claim For Refund Or Credit Form - Bossier City

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CLAIM FOR REFUND OR CREDIT
State of Louisiana
This form to be completed by
Parish of Bossier
the applicant and filed with the
Bossier City-Parish Sales & Use Tax Division
Bossier City-Parish Sales & Use Tax Division
FOR OFFICE USE ONLY
Name of Taxpayer:__________________________________________________________
Date Request Received:________________________
If taxpayer is a corporation, enter corporation name
Represented By:____________________________________________________________
Assigned Auditor:_____________________________
Give name and title
Mailing Address:____________________________________________________________
Total Amount Requested for Refund:
The above representative says that the following statement is true and correct, that he or
she is entitled to the refund requested and that he or she is not delinquent with the
$_____________________________________
Bossier City-Parish Sales & Use Tax Division in the payment of any taxes.
Amount Approved for Payment:
$_____________________________________
Nature of Tax:______________
Period:_______________________________
Submit copies of returns and/or credit memos
Sales or Use
Note:
associated with refund period(s).
Reviewed by:
Total Amount of Taxes Paid:
$__________________________
______________________________________
Corrected Amount of Taxes That Were Due:
$__________________________
Approved by:
Amount Requested to be Refunded:
$__________________________
______________________________________
This refund is claimed for the following reasons:___________________________________
Date:__________________________________
__________________________________________________________________________
__________________________________________________________________________
_____________________________________
___________________________
Signature of Taxpayer
Date

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