Indiana > Statewide > Department Of Revenue > Sales And Withholding
Claim For Refund GA-110L - Indiana
| Claim For Refund Form. This is a Indiana form and can be used in Sales And Withholding Department Of Revenue Statewide . |
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State Form 615 R3 / 2-13 GA-110L Form Indiana Department of Revenue Claim for Refund Mail to: P.O. Box 935 Indianapolis, IN 46206-0935 Call (317) 232-2339 or email refundclaim@dor.in.gov Name of Taxpayer Address City Check One Tax Type State Zip Taxpayer Identification Number Federal Identification Number Social Security Number Cigarette Corporation County Innkeepers Fiduciary Financial Institutions Food & Beverage Gaming Excise Gasoline Hazardous Chemical IFTA Individual IRP Motor Carrier MVR-Excise Oil Inspection Special Fuel Oversize/Overweight Underground Storage Prepaid Sales on Gasoline Withholding Sales & Use Other ___________________ Sales & Use on Utilities Attach ALL documentary evidence to support your claim. Failure to attach all documentation with the claim may result in the claim being rejected or denied. (Please check the box after completing). A completed explanation is required as to why the refund is due. A Power of Attorney (POA-1) form must be completed and attached authorizing the department to discuss your claim and specific tax type with anyone other than the taxpayer. Year or Period Ending Requested Refund Amount Date(s) of Tax Payment(s) Year or Period Ending Requested Refund Amount Date(s) of Tax Payment(s) Total Requested Refund Amount $ I hereby certify that the foregoing account is just and correct; that the amount claimed is legally due, after allowing all just credits; and that no part of the same has been paid. I further understand that this refund may be applied to any liability which I currently have outstanding. Under penalties of perjury, I declare that I have examined this form, including the accompanying schedules and statements, and to the best of my knowledge and belief it is true, correct, and complete. (If you are claiming a refund for a year in which a joint return was filed, each spouse must sign this refund claim.) ___________________________________________ Signature ___________________________________________ Daytime Phone Number Year B & I Number of Return or Liability Number ___________________________________ Printed Name ___________________________________ Email Amount Paid Interest Paid From Interest Paid To ____________________________ Title ____________________________ Date Interest Total Refunded THE SPACE BELOW IS FOR DEPARTMENT USE ONLY Total Amount of Refund(s) Grand Total _____________________________________________________ Auditor/Tax Analyst Originating Refund _____________________________________________________ Supervisor/Administrator _____________________________________________________ Commissioner/Appointee ______________________ Date ______________________ Date ______________________ Date ____________________________________ Account Number Claim Number ____________________________________ American LegalNet, Inc. www.FormsWorkFlow.com Form GA-110L Instructions Complete a separate Form GA-110L for each tax type and location. Fill-in all blanks because any missing or incomplete information may delay the processing of your Claim for Refund or may cause the Claim for Refund to be rejected or denied. Make sure all missing returns have been filed. · · · · · · · Include the taxpayer's name, address, and correct Taxpayer Identification Number with location number. Check only ONE Tax Type. Each tax type requires a separate GA-110L. Attach ALL documentary evidence to support your claim. Failure to attach ALL documentation with your claim may result in your claim being rejected or denied. Include a complete explanation of why the refund is due. Complete and attach a Power of Attorney (POA-1) form authorizing the department to discuss your claim and specific tax type with someone other than the taxpayer. Include each requested refund amount for the appropriate period(s) and the total requested refund amount. Be sure to sign the GA-110L form and include a daytime phone number and email address. Including a correct email address could help expedite the refund process. Please allow 45 days for processing before contacting the department regarding the status of your claim. Please return the application to: Indiana Department of Revenue Enforcement Division P.O. Box 935 Indianapolis, IN 46206-0935 For assistance, call (317) 232-2339 or email refundclaim@dor.in.gov American LegalNet, Inc. www.FormsWorkFlow.com
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