Form Otp 12 - Application For Refund Of Other Tobacco Products Tax

OTP 12

Rev. 5/04

•

P.O. Box 530

Columbus, OH 43216-0530

Application for Refund

Please Insert:

of Other Tobacco Products Tax

For State Use Only

Account number

For the period from

State ﬁ le no.

, 20

Claimant’s ﬁ le number

, 20

, inclusive

1. Name

Print name as shown on license

2. Business address

Street

City

State

ZIP code

3. Mailing address

Street

City

State

ZIP code

(If other than line 2)

Employer Identiﬁ cation Account No.

Social Security No.

4. Federal Employer Identiﬁ cation Account

No. or Social Security number

5. By an illegal or erroneous payment to Treasurer of State ........................................................ $

6. By an illegal or erroneous assessment: Assessment no.

7. Sales outside Ohio.................................................................................................................... $

8. Returns to the manufacturer ..................................................................................................... $

9. Destroyed by taxpayer (prior approval must be obtained) ........................................................ $

10. Total amount of claim ................................................................................................................ $

11. State full and complete reason for above claim

I declare under penalties of perjury that this report, including

For State Use Only

any accompanying schedules and statements, has been ex-

To district

amined by me and, to the best of my knowledge and belief,

is a true, correct and complete report.

Unpaid assessments

Claimant

Payable to Ohio Treasurer of State

Title

Refund due claimant

Date

nstructions: An application for reimbursement of the total

amount allowable on the application for refund ﬁ rst shall

amount indicated above must be ﬁ led in accordance with the

be applied in satisfaction of the debt. A warrant, up to the

provisions relative thereto as set forth in Section 5743.53 of

amount of such indebtedness, shall be drawn payable to the

the Ohio Revised Code. The absence of complete records

Treasurer of State to satisfy the amount due to the state of

in support of the above application will constitute justiﬁ able

Ohio as authorized by Section 5743.53(C) of the Revised

ground for disallowance of the claim. Applications shall be

Code. Any amount in excess of such indebtedness shall be

ﬁ led with the tax commissioner, on the form prescribed by

drawn payable to the applicant.

him for such purpose, within three years from the date of

The applicant should assign a claim ﬁ le number beginning

such illegal or erroneous payment of the tax.

with No. 1 in the space provided. In this way, all claimants

If the applicant who is entitled to a refund under Section

submitting claims will have a claim number sequence. The

5743.53 of the Revised Code is indebted to the state of

claim must be sent to the Department of Taxation, Attn:

Ohio for any tax administered by the tax commissioner, or

Excise Tax & Assessment Unit, P.O. Box 530, Columbus,

any charge, penalties, or interest arising from such tax, the

OH 43216-0530.

Form Otp 12 - Application For Refund Of Other Tobacco Products Tax - 2004

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