Form Ga-110l - Claim For Refund
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1Form
Indiana Department of Revenue
Mail to: P.O. Box 935
GA-110L
Claim for Refund
Indianapolis, IN 46206-0935
State Form 615
Call (317) 232-2339 or
(R6 / 6-13)
email
refundclaim@dor.in.gov
Name of Taxpayer
Taxpayer Identification Number
Address
Federal Identification Number
City
State
Zip
Social Security Number
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Check One Tax Type
Fiduciary
Hazardous Chemical
MVR-Excise
Sales & Use on Utilities
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Aviation Fuel Excise
Financial Institutions
IFTA
Oil Inspection
Underground Storage
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Cigarette
Food & Beverage
Individual
Oversize/Overweight
Withholding
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Corporation
Gaming Excise
IRP
Prepaid Sales on Gasoline
Other ___________________
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County Innkeepers
Gasoline Use
Motor Carrier
Sales & Use
Attach ALL documentary evidence to support your claim. Failure to attach all documentation with the claim may result in the claim being rejected or
denied. (Please check the box after completing).
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A completed explanation is required as to why the refund is due.
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A Power of Attorney (POA-1) form must be completed and attached authorizing the department to discuss your claim and specific tax type with
anyone other than the taxpayer.
Year or Period Ending
Requested Refund
Date(s) of Tax
Year or Period Ending
Requested Refund
Date(s) of Tax
Amount
Payment(s)
Amount
Payment(s)
Total Requested Refund Amount $
I hereby certify that the foregoing account is just and correct; that the amount claimed is legally due, after allowing all just credits; and that no part of
the same has been paid. I further understand that this refund may be applied to any liability which I currently have outstanding. Under penalties of
perjury, I declare that I have examined this form, including the accompanying schedules and statements, and to the best of my knowledge and belief it
is true, correct, and complete. (If you are claiming a refund for a year in which a joint return was filed, each spouse must sign this refund claim.)
___________________________________________
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____________________________
Signature
Printed Name
Title
___________________________________________
___________________________________
____________________________
Daytime Phone Number
Email
Date
▼ THE SPACE BELOW IS FOR DEPARTMENT USE ONLY ▼
Year
B & I Number of Return or Liability Number
Amount Paid
Interest
Interest
Interest
Total Refunded
Paid From
Paid To
Total Amount of Refund(s)
Grand Total
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Auditor/Tax Analyst Originating Refund
Date
_____________________________________________________
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____________________________________
Supervisor/Administrator
Date
Account Number
_____________________________________________________
______________________
____________________________________
Claim Number
Commissioner/Appointee
Date
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Parent category: Financial