TREASURY DEPARTMENT, Ed. 150,000. State of.......... County of... APPENDIX FORM No. 38 CLAIM FOR REFUND TAXES ERRONEOUSLY OR ILLEGALLY COLLECTED. ALSO AMOUNTS PAID FOR STAMPS USED IN ERROR OR EXCESS Date of filing to be plainly stamped here (Address of claimant; give street and number as well as city or town, and State.) This deponent being duly sworn according to law deposes and says that this claim is made on behalf of the claimant named above, and that the facts stated below with reference to the claim are true and complete: 1. Business engaged in by claimant.. 2. Character of assessment or tax.. 3. Amount of assessment or stamps...... (State for or upon what the tax was assessed or the stamps affixed 4. Amount now asked to be refunded (or such greater amount as is legally refundable)..........................---.. 5. Date of payment of assessment or purchase of stamps.. Deponent verily believes that the amount stated in Item 4 should be refunded and claimant now asks and demands refund of said amount for the following reasons: And this deponent further alleges that the said claimant is not indebted to the United States in any amount whatever, and that no claim has heretofore been presented, except as stated herein, for the refunding of the whole or any part of the amount stated in Item 3. Sworn to and subscribed before me this.. day of............ Signed: Write Name so it can be easily read. (This affidavit may be sworn to before a Deputy Collector of Internal Revenue without charge.) |