For Office Use Only Wyoming Secretary of State 2020 Carey Avenue, Suite 700 Cheyenne, WY 82002-0020 Ph. (307) 777-7311 Fax (307) 777-5339 Email: Business@wyo.gov VerifiedClaimForm 226 Revised October 2015 Annual Report Overpayment Verified Claim Form ID#: Name and Address of Entity: Name: Address: The above entity is requesting a refund in the amount of $ for the Annual (dollar amount) (year) Report as evidenced by the attached documentation. The reason for requesting the refund is as follows: Signature: Date: (mm/dd/yyyy) Print Name: Title: American LegalNet, Inc. www.FormsWorkFlow.com