Attn: Revenue Clerk Bureau of Corporations and Charitable Organizations Telephone: 717-772-2708 401 North Street, Room 206 Fax: 717-783-2244 P.O. Box 8722 Website: www.state.pa.us/corps Harrisburg, PA 17105-8722 Email: tblouch@pa.gov PETITION FOR REFUND Please Print 1. Name of Company_____________________________________________________ 2. Person Requesting Refund ______________________________________________ 3. Refund Payable to ____________________________________________________ 4. Taxpayer ID (FEIN) or (SSN) must be provided for payee _____________________ 5. Address to mail refund _________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ 6. Phone Number _______________________________________________________ 7. Reason for Refund_____________________________________________________ 8. Amount to be Refunded________________________________________________ PLEASE RETURN A COPY OF THE FRONT AND BACK OF YOUR CANCELLED CHECK AND THE ORIGINAL NOTIFICATION TO THE ATTENTION OF THE BUREAU OF CORPORATIONS AND CHARITABLE ORGANIZATIONS REVENUE CLERK AT THE ABOVE ADDRESS. Revised 9/2012 American LegalNet, Inc. www.FormsWorkFlow.com