Indiana Department of Revenue Form GA-110L Claim for Refund State Form 154 R2 / 8-08 Mail to: 100 N Senate Ave. Rm N203 MS#105 Indianapolis, IN 46204-2253 Name of Taxpayer Taxpayer Identification Number: Address: Federal Identification Number: City: State: Check Tax Type □Cigarette □Corporation □County Innkeepers □Fiduciary □Financial Institutions □Food & Beverage □Gaming Excise □Gasoline □Hazardous Chemical Zip: Social Security Number: □IFTA □Individual □IRP □Motor Carrier □MVR-Excise □Oil Inspection □Underground Storage □Overersize/Overweight □Withholding □Prepaid Sales on Gasoline □Other ___________________ □Sales & Use □Special Fuel A complete explanation is required as to why the refund is due. Attach ALL documentary evidence to support your claim. Failure to attach all documentation with the claim will result in the claim being returned or denied. Please allow 45 days for processing before contacting the Department regarding the status of your claim. 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 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 ____________________________________ Printed Name _ __________________________________________ _ Daytime Phone Number ____________________________ Title ________________ Date ▼ THE SPACE BELOW IS FOR DEPARTMENT USE ONLY ▼ Year B & I Number of Return or Liability Number Amount Paid Interest Paid From: Interest Paid To: Interest Total Refunded Total Amount of Refund _ ____________________________________________________ _______________________ _ ___________________________________ _ _ Auditor/Tax Analyst Originating Refund Date Account Number _ ____________________________________________________ _______________________ _ Supervisor/Administrator Date Claim Number: _ ___________________________________ _ _ ____________________________________________________ _______________________ _ Commissioner/Appointee Date American LegalNet, Inc. www.FormsWorkflow.com