Claim For Refund Of Taxes Paid Form

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C
R
T
P
LAIM FOR
EFUND OF
AXES
AID
City of Baton Rouge/Parish of East Baton Rouge
Department of Finance – Revenue Division
PO Box 2590
Baton Rouge, LA 70821-2590
(225) 389-3084
Taxpayer Name:
Tax Account Number:
Business Address:
Business Phone:
Contact Person:
Title:
E-Mail Address:
Type of Tax:
Period(s):
(Month and Year)
Preferred refund method:
1.
Taxes remitted:
$
Credit Memo
2.
Taxes due, as amended:
$
Refund Check
3.
Refund requested:
$
Providing appropriate documentation for refund requests will expedite the refund claim. For example, original invoice, credit
invoice, original tax return, proof of payment. For bad debt write offs, please supply the state’s approval letter and the
corresponding federal income tax return.
This refund is claimed for the following reasons:
Signature of Taxpayer:
Date Prepared:
This form must be notarized if the claim is greater than $1,500
Sworn to and subscribed before me this _______ day of _________________________, 20_____.
Taxpayer:
(Signature of Notary Administering Oath)
(Name and Title)
The above deponent, being duly sworn, deposes and says that the
For Office Use Only
following statement is true and correct, that he is entitled to the refund
Date Received:
requested and that he is not delinquent with this City or Parish in the
Refund Project:
payment of Sales Tax, Use Tax, Hotel-Motel Tax, or Occupational
License Tax.
Revised 4/2010

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