HomeMy WebLinkAbout660219.tiffForm DR 137
R, ... 8 RECtivEn 110. 23
AUG 3 0 1965
DEPT. OF REVENUE
STATE OF COLORADO
DEPARTMENT OF REVENUE
Capitol Annex" 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 de°sit paid.
State of
County of
Name of Taxpayer
Type
or
Print
Account Number (Social Security or Assigned) of Taxpayer
Address
City Zone State n
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 ,.19 , to , 19
3. Character or kind of tax or deposit
4. Dates of payment i
5. Amount of tax and/or deposit paid $
6. Correct Amount of Tax Liability $
7. Amount to be Refunded $
Reasons for Claim:
(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 (inducting 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 accompanied by power of attorney. (See Instruction)
8/22/66 Weld County, Colorado
(Signature of pt.22,u, oth taxpayer, preparing this claim) (Date) (SI lure of Taxpayer)
Chaix(RWM), Board of County Commissioners
(See Instructions on Reverse Side)
.. ) /
.... (Name orm or or mployer, If any)
-9
CERTIFICATE
fFor use of the Department only)
Date of Claim
Kind of Tax
Tax Period ending
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
DEBil
CREDIT
BALANCE
Mo.
Day
Yr.
i
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c I
-t
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Date Certified
By Accounts Division
Refund of Credit Balance 0 Refund of Deposit D Refund allowed as claimed on reverse side ❑
Amount claimed on reverse side adjusted by following corrections ❑
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
..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 he 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 authenticated copy of the document specifically authorizing such an agent, or attorney to sign the
claim on behalf of the taxpayer should accompany the claim.
3 When, the taxpayer is a corporation, the claim shall be 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 fine of $500, or minimum sen-
tence of ninety days or both Appropriate penalties apply to filing false claims for refund of other taxwe.
DR -513 STATE OF COLORADO
DEPARTMENT OF REVENUE
CONTRACTOR'S CERTIFICATE �
STATE OF COLORADO ) O'"
J.yf
ss. 'n, ,l, q
COUNTY OF )
I,- , of lawful age, being first
duly sworn, depose and state: That I am the '.re.6lu. r of the
(Title) ,.
7. ,, c. contractor for the construction of a
(Type ofStructure)
for , in the County of to , State of Colorado;
(Owner)
That State of Colorado sales tax in the amount of $ ;-.. , and/or
Use tax in the amount of $ , which said c, curb
(Owner)
seeks to have refunded, was paid by said contractor, or his sub -contractor, between the
dates of
1, 19 and 19 i`.; that the tangible per-
sonal property upon which said State of Colorado tax was paid was built into the above -
mentioned
(Type of Structure)
Affiant further states that the books, records and other substantiating evidence
of payment of said taxes are located at v.' -, r e c , 1,r- a 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)
signature)
e . See attached breakdown, Form DR -513 A.
ti
Subscribed and sworn to before me this 1 day of I]-1,SL 19_
My commission expires
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
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