26 CAR pt. 6, Appendix A. Claim for Reimbursement

CLAIM FOR REIMBURSEMENT Claimant's name: ________________________________________________ Address: ________________________________________________ ________________________________________________ Sales tax permit #: ________________________________________________ Or Social Security #: ________________________________________________ I hereby swear and affirm that I have sustained actual damages in the amount of $_________________________ as a result of a collection activity of the Department of Finance and administration and request reimbursement. The facts upon which my claim is based are as follows: ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ The error of the Revenue Department which lead to my actual damages was ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ I responded to the following contacts by the Revenue Department and provided the requested information sufficient to establish my position as follows: ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ________________________________ CLAIMANT