HomeMy WebLinkAbout660220.tiffNorm DR 137
Rry 8 '6I
STATE OF COLORADO
DEPARTMENT OF REVENUE
Capitol Anrex Building
Denver
CLAIM FOR REFUND
Claim No
Account No
Return No
Voucher No
To be filed in Duplicate for each kind or character of tax and/or deposit paid.
State of Q oj.orado
Weld
County of
Type
or
Print
Name of Taxpayer
Weld County Colorado
Account Number (Social Security or Assigned) of Taxpayer
Address weal ri f'.rnnnty arotri kcittsa
City Greeley, Zone t State Colorado
The undersigned certifies that this statement is made on behalf of himself or the taxpayer named, that the
facts given below are true and complete, and avers that the claim should be allowed for the reasons stated below.
1. Date on which return and/or deposit was filed
2. Period from May__l 19_66._._, to June_30 ,
3. Character or kind of tax or deposit Sal.es._Tax_
4. Dates of payment through--June__30, 1966
5. Amount of tax and/or deposit paid $ 24.20
6. Correct Amount of Tax Liability $ 24.20
7. Amount to be Refunded $ 2a .20
Reasons for Claim:
EXEMPT
(Attach letter size sheets if space is not sufficient)
Claim for refund of a specific tax must be made within the time limits and be supported by the required
documents, all in accord with the provisions of the particular statute relating to such tax. For refunds where
no particular refund law applies, see Chapter 130-2-5, Colorado Revised Statutes 1963.
I/we declare, under the penalties of perjury, that this claim (Including any accompanying schedules and statements) has been examined by
me/us, and to the best of my/our knowledge and belief is true, correct, and made In good faith, for the purposes stated, pursuant to the Colorado
Laws and the Regulations issued under authority thereof.
A claim made by an agent must qq accompanied by power of attorney. (See Instruction)
8/22/65 Weld County, Colorado
(Date) gnature of Taxpaye,
(Signature son ry�art taxpayer, preparing this claim)
(Name of firm or employer, if any)
(Date) Chairman, Board of County Comsnrs.
(See Instructions on Reverse Side)
CERTIFICATE
, Jr use of the Department only)
Date of Claim
Kind of Tax
Tax Period EndNg
Account No.
I
Comp I
Typ.
I P.R.
I certify that an examination of the records of the Department of Revenue shows the following facts:
BATCH DATE
VALIDATION
NUMBER
REPORT
PERIOD
DOC
TRAN
DEBIT
CREDIT
BALANCE
Mo.
Day
Yr.
1
-L
+ -
I
4
4
7
_H�
I
I
_I
I
I
i
I
I I
Y -
I
Date Certified
By .... - - - . ... ..-------- Accounts Division
Refund of Credit Balance 0 Refund of Deposit 0 Refund allowed as claimed on reverse side 9
Amount claimed on reverse side adjusted by following corrections 0
Accounts adjusted concurrently by Form for $ Debit ❑ Credit ❑
I certify that I have made an examination of the
claim and facts submitted and recommend that the
amount indicated herein be refunded:
Amount claimed $ _
Amount of claim rejected
Refund increased
Amount of tax and/or bond allowed
Amount of interest allowed
Total refund allowed $
Audited By __— — - _Reviewed By:._ ___ __—_ --_ _ — Date___
Approved By _ __ Supervisor.
I hereby authorize the refund of $_ _ _ _ __ ____ —__.as recommended in the report of the examining officer.
Approved for Payment
1
--Assistant Director
Deputy Director
Director of Revenue
INSTRUCTIONS
1. The claim must set forth in detail each ground upon which it is made, and facts sufficient to inform the Department of Revenue of the
exact basis thereof.
2. The claim should lw signed by the taxpayer, if possible. Whenever it is necessary to have the claim executed by an attorney or agent,
on behalf of the taxpayer, an ant hem is a led copy of the document specifically ant horiz ing such an agent, or attorney to sign the
claim on behalf of the taxpayer should accompany the claim.
3. Where the taxpayer is a corporation, tt.e claim ehall he signed with the corporate name, followed by the signature and title of the
officer having authority to sign for the corporation.
4. Separate claims for Income Tax Refund must be made for each taxable year. (Original and one duplicate copy must be signed by the
taxpayer and returned to this office.)
5. Any false statement made by applicant for Sales Tax refund is punishable on conviction by maximum title of $500. or minimum sen-
tence of ninety dens or both. Approp:'iutr penalties apply to filing false claims for refund of other taxes.
DR -.513
STATE OF COLORADO
DEPARTMENT OF REVENUE
CONTRACTOR'S CERTIFICATE
STATE OF COLORADO
) ss.
COUNTY OF
I. E.Y. Addison , of lawful age, being first
duly sworn, depose and state: That I am the Treasurer of the
(Title) Addition
Addison & Glenn, Inc. contractor for the construction of a to Nursing Home
(Type of Structure)
for Weld County , in the County of Weld , State of Colorado;
(Owner) /
That State of Colorado sales tax in the amount of $ 24y 20 , and/or
Use tax in the amount of $ None , which said Weld County
(Owner
seeks to have refunded, was paid by said contractor, or his sub -contractor, between the
dates of May 3, 19J41. and ,hrne 30. 19 6F,; that the tangible per-
sonal property upon which said State of Colorado tax was paid was built into the above -
mentioned Addition to Weld Co. Ntiysing Home
(Type of Structure)
Affiant further states that the books, records and other substantiating evidence
of payment of said taxes are located at 314 -25th Avenue, Greeley. Colorado in said
(Office Address - Street and City)
County and State; and that the same are open to inspection by the Department of Revenue.
(Contractor's signature)
Subscribed and sworn to before me this 12 day of August 1966
My commission expires March 9, 1969
See attached breakdown, Form DR -513 A.
Notary Public
ARCHITECT'S CERTIFICATION
I hereby certify that the property on which the tax has been paid has, in fact,
been built into the property of , by said contractor, in
accordance with the specifications of the contract and in the amount shown herein.
Date
STATE OF COLORADO - DEPARTMENT OF REVENUE
c▪ d
U
.r,
F▪ .
U
U)
F.
0
N
U
,U
F.
4'
C
0
U on H .
Q1
A
A �
E A
O +)
U)
a e
0
0 0
U 0
•
17 b d
O U) 1-.
O -, 0
U) .r, +>
'd U
°UP
• -P
.0 O N
U )d
N U)
-P - C
(1)
-I-I W
r1 1-•
O
N
4-1 O A
• N
O
• ._
C
w C
•�w cld
10 E
H •r, Cl.
U ;3:
O N
r
♦ E
›-.• 4-1 E
U
H U) W
O � A m +3
C cu o
...I CC
U) ..1
U) U) d
• 7 .,
O O 2!
F. • U) N
0., 1 444o �.
N•cJ.�
H
+I 0) to
v N
.-) 4. a
V)td r, .r,
•r, N a)
ra U) U
rl -I
CJHri
03 U
Si (0 C
•ri
S ri
f'1 ri E
r-, -r, O
v1 s :z
pp
Type of Material (cement; re -bar
structural steel; flooring, etc.
W
O O co
b Di
0 FS. H
O
O O r, (1)
U
Amount of
Colorado
Sales Tax
‘)
LO -'O o'ON
N -.O )n r• t--- 0`
)n 3 N
oi)
O
N
—
n
43-
W tU
>-
O-�r
+) U) C
U) I) 0
c0) S
O
F'
O
-,
0
O N)
ri
44 8
N U) ,d
it) Y U) E
O
CU rl U)
C 0� C H F. 00 rl
H )C O rfl 0I
C7 0 .C F. r,
ozi o P.owa H
0 0 O a) H -P +)
4 0 U) tE E
U) N ,C •rl
l C U) - U rd
'd ,d P C +) Fi
r)
a a Q Q Z "
Invoice
List each secarately
'':111,11-Ar mate
STATE OF COLORADO - DEPARTMENT OF REVENUE
+a
U
U
-rl
r1
Ii
a,
ac
v
w
0 O
KK
U
)d
-,
0
v
e
rlif\ TS
a)
E
O +a
W
CI
e
0 0
ri
at
U • O
td
O a)
0) .c+o
U
O� 4+� a
p b U)
O tU
+� -.C
4-1 ca u
aw
rl FS 0
_c 1.4
RI
O o a
0
pi
Iw
a
O c
0)
O u 0
U
O y O
C N
C W) O
Ul C C
U) .
U ) O U) 'd
a) 7 1
U [7
• U) N
a. 7,-. )u
a) v +�
4-2
+.) v m
4)
4) 4)
a c, ,>
US o •rl
4-)
• N 44 a)
I -I N'CI
•fl .rl 0
U rlrl
at U
4 N
ri -rl 0
's z
q -II
Type of Material (cement; re -bar
structural steel; flooring. etc.
4
�
il---
3
PCB)
t---4 ` y
�
Amount of
Colorado
Use Tax
Amount of t
Colorado
Sales Tax
\ o n,
J
--.3Q- O -1, p 'y -4. ci o et.....y` �i
` `7
Cost of '
material
only
Ni 1- rtl k
V
L-1 9")' \ s K Z:.` - V` s ; ` ,c);n 7 ` R
M
O
.O
c5 3 c3
1 cl
qq
U v
Q
CI
--
'1
r
c,
.1
-4,
cr rt) 3C?
j
G #1 i
j
f
o {
�
C4 r3 c S c� Ci ,-8<
i.
S a
S
m
i
Invoice
List each separately
'.: iimhrr late
V 0.- Is? V a\ 7
ry
' n .1.
ot.r
CE
O n az 7` A Off. \O `E X 7` 7. d O O 1 :` t�J M i Q
ON. v N. t. N. DO CO CO o• o o. 7-r)
O0• o. 0` o\ o. 0% o.o� 0.- o O 0 0 0 O 00oOt
WELD COUNTY, COLORADO
WAIVER AND RELEASE
For value received
hereby waives any lien (he or it) has or may have the right to take, for
any labor or material furnished by (him or it) and certifies that (he or
it) has been paid in full for any and all labor or materials furnished
by (him or it) to WELD COUNTY, COLORADO, and that (he or it) has no claims
in law or equity of any kind against WELD COUNTY, COLORADO, for any labor
or material furnished by (him or it) for and toward the construction or
improvement of building or buildings or other improvement put upon the
following described premises:
In
19
witness whereof, I have hereunto set my hand and seal
at
, State of Colorado, this /J day of (,ecz,c4„,
Clc[cE� a.� (SEAL)
WAIVER AND RELEASE
For value received 4-e tv"Z t� E- s z c / ��i z L 7` hereby waives any
lien (he or it) has or may have the right to take, for any -labor or material furnished by
t•him or it) and certifies that (he or it) has been paid in full for any and all labor or ma-
terials furnished by (him or it) to WELD COUNTY, COLORADO, and that (he or it) has no chins
in law or equity of any kind against VIELD COUNTY, COLORADO, for any labor or material furn-
ished by (him or it) for and toward the construction or improvement of building or buildings
or other improvement put upon the following described premises:
77
,, uO_ nJ /4/ %'o
L/
In witness whereof, I have hereunto set my hand and seal at eft e0
State of Colorado, this
/I
day of (Lit .yiti, / , 1966.
u 2{/L4/.// -c--('SEAL)
STATE OF COLORADO - DEPARTMEIT OF REVENUE
a)
EA
O +)
w
W E
O
A .rl
O 0
U al
c b a)
O a) 1.
w .ad 0
U
+ )a,
,x) O N
a [a
0 0
.a
)
• N
W
.t O
4 1 1-•
• c s-
+) ai
O • o 0.
O
4
w{4a)
•r+Or�
w
• to E
ri r O.
0
o gel
W w w
o c .0
4-)
m al
C U) O
.te r a
U ) ..4
LO U) d
a) :7 •ri
o -d
O -
{. 0) t)
a i
• :.
a) 'U
.N a) N
4) • 0
)
as c]
r1 0)
▪ U) m o
.r4
U )a U.)
WELD COUNTY, COLORADO
WAIVER AND RELEASE
For value received
hereby waives any lien (he or it) has or may have the right to take, for
any labor or material furnished by (him or it) and certifies that (he or
it) has been paid in full for any and all labor or materials furnished
by (him or it) to WELD COUNTY, COLORADO, and that (he or it) has no claims
in law or equity of any kind against WELD COUNTY, COLORADO, for any labor
or material furnished by (him or it) for and toward the construction or
improvement of building or buildings or other improvement put upon the
following described premises:
In witness whereof, I have hereunto set my hand and seal at
, State of Colorado, this iL day of a
edr,J(SEAL)
STATE OF COLORADO - DEPARTMENT OF REVENUE
9,
{r
N
U
N
0
0
U
N
0
0
U
(113)
b
E
O +4
W 0
E
0
+>
a..ra
U ai
-0 a)
o a k
• 0
d
• N•rl +3
N U
O a
44 al
O c▪ t
N N
44 0 a
N N
-ri W
r+ 3 O
H
U
O 0 a
0
• c
w k m
.ri 0 C
w N
rii w E
• 3 0.
O ct
H 0110 • a
w
C O
C C
C
C
U) U) U) .U)
23
0 a) 7 .i
ri +) a)
+ N 'U
-ri
0
r_IH
td 0
H qi C
-H
s H
c'1 ri F
r-i rl 0
v' s z
n H n
WAIVER AND RELEASE
For value received Dean Duncan Roofing
lien (he or it) has or may have the right to take, for any labor or
1him or it) and certifies that (he or it) has been paid in full for
terials furnished by (him or it) to WELD COUNTY, COLORADO, and that
in law or equity of any kind against WELD COUNTY, COLORADO, for any
ished by (him or it) for and toward the construction or improvement
or other improvement put upon the following described premises:
Weld County Nursing Home
11th Avenue and 16th Street
Greeley, Colorado
hereby waives any
material furnished by
any and all labor or ma -
(he or it) has no claims
labor or material furn-
of building or buildings
In witness whereof, I have hereunto set my hand and seal at Greeley
State of Colorado, this 4th day of August
, 1966.
(SEAL)
OF REVENUE
Q)
(d
U
4.1
i3
L�
a)
4-3
O
U
0
U
H 4)
U
.C b N
O ,U L,
o
O N U
o 4) E
N
'tea)
4-)
+3 N
•r1 4i
ri i3 O
r-14-1
-5 1-4
►) (d
O a.
O
41 E a)
4-i
r� :10 E
O (d
ri
O O E
ys 4i f )
U
44 CO 41
O ,0
GO +�
C t 0 ()
W ..-1
u) u) t7
U 'd
O
14 ID +-)
fa. 14 (d
o,d
.G 1"
47 N
any
(d c': •rl
• •-4 +3 a)
ri N
O . 1(4
(d U
4i (d C
•rl
r-1
H H
•.4 0
's z
4-)
A +-)
1 4)
a)
L.
1)0
+> -r4
O La
4) O
E O
4) H
U 44
o O
0 CO CO
0 o
oHn)
U Ol
4i
0 0
t.
O
O r-1 H
U fn
)9.1j
as
4)
�J `
L.
4)
c,
WELD COUNTY, COLORADO
WAIVER AND RELEASE
For value received
O
hereby waives any lien (he or it) has or may have the right to take, for
any labor or material furnished by (him or it) and certifies that (he or
it) has been paid in full for any and all labor or materials furnished
by (him or it) to WELD COUNTY, COLORADO, and that (he or it) has no claims
in law or equity of any kind against WELD COUNTY, COLORADO, for any labor
or material furnished by (him or it) for and toward the construction or
improvement of building or buildings or other improvement put
following described premises: /{L 'L.c^-451- ` Z'z- u —
it //' l/ 614 -r_,
upon the
z1/4712-6
In witness whereof, I have hereunto set my hand and seal at
.7;2 €_c /e7/ , State of Colorado, this
19.
day of r lug/ ,
(SEAL)
STATE OF COLORADO - DEPARTMENT OF REVENUE
a,
4)
a)
y.1
U
a)
O
O
+>
U
ra
1ti
C
0
U
el e
ra)
EA
0+>
Ni
w
0
-0
ab
0 4
o
_C b a)
O a) 1.
a) .'+o
U
.)0)4
f� y N
Oct
it a)
-0 o -0
a) -0
�w
1 3 0
0+ -
Si
0 o
0
C
w a)
.r1 w
)0
`I ri a r
o;3
0al
vell
0 0
a cH O
U
0 -C
C Gq o
.i C C
u) to Cl
U , -Ci
i. L) +)
5. )a
0
,C C
+) a) to
)
4
4) Q
+> w �
ft C •ri
4-)
• ri +> U
r N 'U
Ur11rr1
it U
w N C
d
M H
r I .-1 O
s z
pp
Q 1-1 Q
Type of Material (cement; re -bar
structural steel; flooring, etc.
i-
r
Amount of
Colorado
Use Tax
Amount of
Colorado
Sales Tax
I3
.lb
Cost of '
material
only
v
V
l'J
cb
N
Vendor's Name
*, N.?
Z --j3
V
Invoice
List each separately
'hII9hpr .Date
3
1.
T
NI
X
r J
WELD COUNTY, COLORADO
WAIVER AND RELEASE
For value received nnNs flepppAJi:v L_?e L1/n F. (..(x.VA/d d.o/e//
hereby waives any lien (he or it) has or may have the right to take, for
any labor or material furnished by (him or it) and certifies that (he or
it) has been paid in full for any and all labor or materials furnished
by (him or it) to WELD COUNTY, COLORADO, and that (he or it) has no claims
in law or equity of any kind against WELD COUNTY, COLORADO, forany labor
or material furnished by (him or it) for and toward the construction or
improvement of building or buildings or other improvement put upon the
following described premises:
Weld County Nursing Home
11th Avenue and 16th Street
Greeley, Colorado
In witness whereof, I have hereunto set my hand and seal at
Greeley
, State of Colorado, this
4th day of
August
,
(SEAL)
STATE OF COLORADO - DEPARTMENT OF REVENUE
a)
a
0
r1
w
•ri
a
4)
U
in
Le
O
a
cd
F
a
O
O
U
1
e
r-i N
V1�
d
e A
O a
w �
w �
O
ao
o o
O m
m ) �
0) rI a
o a
O
,c7 N
O d
al N
a w,C
44 0) a
• U
.ri 44O
ri
o
rl w-• 44
• o A.
O
• +0
w 0)
O C
w cd
rrl • LU E
r• ri a
O :
O cd
O o E
9 w 0
0
CH 414
O s A
m a
C Lp O
.r1 C C
co) ..1
U) U) '[j
4 O -r1
o Cj
O
L. 0) a
a1- td
o r.
. II a
.a c
4-1 4) in
P. 0
4) 4)
a w a
cd O .
a
.-1 a 4,
r-1 a 'O
O ,1
cd U
H It C
.d
-4 r'1
1 4-1 E-4
4- r-1 .r1 O
V1 S z
n
Type of Material (cement; re -bar
structural steel; flooring, etc.
Amount of
Colorado
Use Tax
Amount of t
Colorado
Sales Tax
V
Cost of '
material
only
U)
4.
0
4i
CG
-„j
C
Ci
- 1A
QIC
Invoice
List each separately
immner mate
Ny
o,
1.
WAIVER AND RELEASE
For value received Ctz,c, A
c z z� hereby waives any
a e lien (he or it) has o may have the right to/a, for any la or or material furnished by
l'him or it) and certifies that (he or it) has been paid in full for any and all labor or ma-
terials furnished by (him or it) to WELD COUNTY, COLORADO, and that (he or it) has no claims
in law or equity of any kind against YIELD COUNTY, COLORADO, for any labor or
i-bed by (him or it) for and toward the construction or improvement of
or other improvement put upon the following described premises:
In witness whereof, I have hereunto set my han and seal at
State of Colorado, this t day of to
7C C c LA
material fu
building or buildings
(SEAL)
STATE OF COLORADO - DEPARTMENT OF REVENUE
(Contractor's Certificate)
O -f)
N
O
d
ad=
O 0
U 0
U 4) F.
N ri 0
N O .03
N U
+> W
d N
41
O N
N N
)d
r1 W
r 3 O
-H f.
• -0 )d
• O
O
c
W
.,i O r�
w
.n toE
.4 .H a
U 0 td
0 -
d)
O U C)
A W C)
U
144 C 1/414
o P
a
ha .
C c C.
)
G C
U) C
Y) .,
N U)'d
C) 7 .1
O d
O
{ 4] 'd
C1 o cd
o
,C • c:
-P Q) in
4) N
W
N O •H
• rl U) CO
i N 'd
•o H ri U 1
N U
CH d C
r4
a r1
(� ri H
.-1 -H O
V\ s 2
Type of Material (cement; re -bar
structural steel; flooring, etc.
Amount of
Colorado
Use Tax
Amount of f
Colorado
Sales Tax
Cost of '
material
only
`vendor's Name
Invoice
List each separately
s,,,mhpr. Date
t
j.
WELD COUNTY, COLORADO
WAIVER AND RELEASE
For value received
Mitchell Floor Covering
hereby waives any lien (he or it) has or may have the right to take, for
any labor or material furnished by (him or it) and certifies that (he or
it) has been paid in full for any and all labor or materials furnished
by (him or it) to WELD COUNTY, COLORADO, and that (he or it) has no claims
in law or equity of any kind against WELD COUNTY, COLORADO, for any labor
or material furnished by (him or it) for and toward the construction or
improvement of building or buildings or other improvement put upon the
following described premises:
Weld County Nursing Home
11th Avenue and 16th Street
Greeley, Colorado
In witness whereof, I have hereunto set my hand and seal at
Greeley , State of Colorado, this 4th day of
19S.
August
r
t2;‘,<(( 6t
--(SEAL)
STATE OF COLORADO - DEPARTMENT OF REVENUE
(Contractorts Certificate)
44
a. -0
o b
U
•
• N
O 4) U N R.
tl i
o N ri 0 t)
N U
•0 N E
.cl b co
U al
N 0
+ ) .�
t�tl
i W
ri 3 0
r- -.
.C t.
+) N
O o P
0
W 0
r o
W
h0 E
r4 rI 0.
U ;#
O N
ri
-1
- GO. E
U
O • -c P
m • N
C LA 0
J c C
U) U) 'd
tl)
U
Q. L'U
O 7:
a) •U
c
{) U) N
✓ k
4) N
ai U .{
.-, • C rl
U r4 r)
N U
W b
r Hti
r+ a 0
s
,1 8 q H
Type of Material (cement; re -bar
structural steel; flooring, etc.
vVj .
y
\� J
ry rry
4
Amount of
Colorado
Use Tax
Amount of
Colorado
Sales Tax
Cost of '
material
only
V v
)f, Ni
C.. LC) LP
0
.,y
us
V
r r
- ,
At
v?
J •1 J
`J v
Invoice
List each secarately
Date
v ,-a
w
T
c) N ,c
V a -may
"\ G
°::.) v <,
G
WELD COUNTY, COLORADO
WAIVER AND RELEASE
For value received Straight and Seeelke
hereby waives any lien (he or it) has or may have the right to take, for
any labor or material furnished by (him or it) and certifies that (he or
it) has been paid in full for any and all labor or materials furnished
by (him or it) to WELD COUNTY, COLORADO, and that (he or it) has no claims
in law or equity of any kind against WELD COUNTY, COLORADO, for any labor
or material furnished by (him or it) for and toward the construction or
improvement of building or buildings or other improvement put upon the
following described premises:
Weld County Nursing Home
11th Avenue and 16th Street
Greeley, Colorado
In witness whereof, I have hereunto set my hand and seal at
Greeley , State of Colorado, this 4th day of August
19b&.
STATE OF COLORADO - DEPARTMENT OF REVENUE
1
U
U
ri
w
e
A
4)
O ♦>
Cs. W
W E
O
+)
ab
o • ro
O O 4
U N {o
rorl
✓ .rl4-)
O
U
a • 0
d a
O ct a)
)▪ •
ro O
rl W
r-) k O
ri i-.
N i,
• O a.
O
W 0 • F
N
•ri U
W
• !+D E
Ci a
U ;3
O ro
ri
O O
:3'4 W C)
U
W W y
O _c
00 .>
• tall O
C C C
V) .U)
U )
4) U) 'r
7 r4
U O
$-i • Ci) },
a Si +4
a)
.e C
+ � 4) U)
4) N
C)
r -1 4)
r
✓ ri ri
N U
W N C
.ri
(- ri
rj -riri 0
n s Z
n
Type of Material (cement; re -bar
structural steel; flooring, etc.
C
Amount of
Colorado
Use Tax
Amount of
Colorado
Sales Tax
Cost of '
material
only
Vendor's Name
Invoice
List each separately
Pinmhwr Date
r �"K
C)
',9
Hello