Application For Credit/refund Of Fees Paid On Mining Claims Form Page 2

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THIS PORTION TO BE COMPLETED BY DEPARTMENT OF TAXATION
Verified Payment
Recorder
Yes
No
Treasurer
Yes
No
Amount of Verified
Claim:
$________________________
Employee Initials ____________
Was payment received
Yes
No
Employee Initials _____________
by State Comptroller?
Active MBT Account:
Yes
No
Tax ID # :
Reporting Liabilities
Yes
No
Going Forward:
Amount of Credit:
Date to Accounting:
$______________________
Amount of Refund:
Date of Notification to Claimant of
Department Decision:
$______________________
Completed by:
Date Application Received:
Date to Board of Examiners:

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