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
to
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
I
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.