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970507
Dr. 0157 (12,89)
State of Colorado
Deparhnent of Revenue
1375 Sherman Street
Denver CO 80261
CLAIM FOR REFUND
(Do not use for income tax refund)
Validation Number:
Do Not Write in Above Space
• Submit separate claim for each type of tax (e.g. state sales, RTD/SCFD, city sales, county sales, etc.b RECEIVED
• Periods can be combined if consecutive for each type of tax.
• Submit white copy. Retain yellow copy for your records.
• Claims must be accompanied by amended returns, or substantiated evidence to support claim.
•
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Taxpayer Name:
Mt.c_hel(C l _)UhnAon ,,bnc .
Taxpayer DBA (if applicable):
Mailing Address: /�
7(9 'RC/ Cn rn linca . ILO('
City, State, Zip:
Lbnci/nnf (r) 2U57j %
.—/
Account Number:
Type of Tax:
Period (moryr-mo/yr):
Ori l Am nt Paid:
7 (FG . 2 5
Correct Amount:
Refund Amount Requested: ._.-
Sr 4196. a S
y�rq oronase separate paperpp
Reason:(Ezplain below p D D
needed) All supporting documentation must be attached.
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COLORADO
LIQUOR
1881
LAKEwOOD
_
DEPT OF REVENUE
ENFORCEMENT DIVISION
PIERCE STREET RM 108A
CO 802144495
I declare under penalty of perjury in the second degree that this claim, including all attachments, is to the best of my knowledge true and
correct.
Taxpayer Signature ^ and Title:{ I 7
k. o I�.1 i 1. t , l
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relephone Number`::
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Date: p
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Signature o reparer (if other than taxpayer):
'
Te ephone Number:
Date:
o not write below tills line. For Department of Revenue Use Only.
Comments:
°AT
I certify that I have made an examination of the documents and facts related to this claim.
Tax Examiner:
Date:
1st Approver:
Date:
2nd Approver:
Date:
3rd Approver:
Date:
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