Petition For Refund - Pennsylvania Department Of State
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Attn: Revenue Clerk
Bureau of Corporations and Charitable Organizations
Telephone:
717 -7 87 -1057
401 North Street, Room 206
Fax:
717 -783-2244
P.O. Box 8722
Website:
Harrisburg, PA 17105-8722
PETITION FOR REFUND
Please Print
1. Name of Company_____________________________________________________
2. Person Requesting Refund ________________________________________ __ ____
3. Refund Payable to ____________________________________________________
4. Taxpayer ID (FEIN) or (SSN) to be provided for payee ________________________
5. Address to mail refund _________________________________________________
______________________________________________________________________
______________________________________________________________________
6. Phone Number _________________________________________________ __ ____
7. Reason for Refund_____________________________________________________
8. Amount to be Refunded_________________________________________________
PLEASE RETURN A COPY OF THE FRONT AND BACK OF YOUR CLEARED
CHECK AND THE ORIGINAL NOTIFICATION OF REFUND TO THE ATTENTION OF
THE BUREAU OF CORPORATIONS AND CHARITABLE ORGANIZATIONS
REVENUE CLERK AT THE ABOVE ADDRESS.
PLEASE ALLOW 6 - 8 WEEKS FOR RECEIPT OF REFUND.
Revised 11/15/2012
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Parent category: Financial