ARSD 20:06:16:01. Claim form

The form to be used for requesting a premium tax refund shall be provided by the division and shall contain the following information: (1) The date of the application; (2) The name of the company requesting the refund; (3) The address of the company requesting the refund; (4) The period of time for which the refund is claimed; (5) The amount of the claim; (6) The basis for the claim; (7) The signature and title of the person entitled to make the claim; and (8) An attestation of the signature by a notary public.