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Form Rv-F1402101 - Unlicensed Exporter Claim For Refund - Tennessee Department Of Revenue

PET

380

TENNESSEE DEPARTMENT OF REVENUE

UNLICENSED EXPORTER CLAIM FOR REFUND

Name of Claimant __________________________________________

SSN/FEIN ____________________________________

Location Address __________________________________________

Account No. ___________________________________

City, State, ZIP _____________________________________________

Claim Period:

Beginning ______________________

Mailing Address ____________________________________________

Ending ________________________

City, State, ZIP _____________________________________________

Date of Claim _________________________________

EXPORT GALLONS

OATH OF TAXPAYER

Under penalties of perjury, I declare that I have examined this claim, and to the best of my knowledge and belief, it is true, correct,

and complete.

Name __________________________________________

Title ___________________________________________

(Signature of Taxpayer, Officer, or Authorized Representative)

FOR OFFICE USE ONLY

CHECKED BY

DATE

APPROVED

REASON FOR REDUCTION

REFUND NO.

REDUCED

PROCESS COMPLETION DATE

INCREASED

APPROVAL

Approved Amount $ ______________

__________________________________________

________________________________________

_____________

Director or Designate

Commissioner of Revenue or Designate

Date

INTERNET (4-03)

RV-R0010001

Form Rv-F1402101 - Unlicensed Exporter Claim For Refund - Tennessee Department Of Revenue