SV 4 
                       Department of                                                                                                                       Rev. 4/08 
Ohio                   Taxation 
                       P.O. Box 530 
                       Columbus, OH 43216-0530 
        Please Insert                                                                                                                        For State Use Only 
        Account No.                                                                                                                          State File No.

                                               Application for Refund
Claimant’s File No. 
                                                 of Severance Tax 

For the period from                                          , 20 to                                                                         , 20 , inclusive. 
1. Name 
                                                             Print name as shown on license 
2. Business address 
                                    Street                                 City  State ZIP code                                                    
3. Mailing address
(if other than line 2)              Street                                 City                  State                                            ZIP code 
4. Federal employer identifi cation account number            Employer Identifi cation Account No. Social Security No. 
  or Social Security number ................................ 

5. By an illegal or erroneous payment to Ohio Treasurer of State ..................................................$ 

6. By an illegal or erroneous assessment: Assessment no.                                          ......................$  

7. Total amount of claim ..................................................................................................................$ 

8. State full and complete reasons for above claim 

                                                                  I declare under penalties of perjury that this report, includ-
                       For State Use Only 
                                                                  ing any accompanying schedules and statements, has been 
To district                                                       examined by me and, to the best of my knowledge and belief,  
                                                                  is a true, correct and complete return and report. 
Unpaid assessments 
                                                                  Claimant 
Payable to Treasurer of State 
                                                                  Title 
Refund due claimant 
                                                                  Date 

Instructions: An application for reimbursement of the total       which is due and payable shall be certifi ed to the auditor of 
amount indicated above must be fi led in accordance with the       state by the tax commissioner with his determination upon 
provisions relative thereto as set forth in Ohio Revised Code     the application for refund.  A warrant, up to the amount of 
section (R.C.) 5749.08. The absence of complete records           such indebtedness, shall be drawn payable to the Ohio                                          
in support of the above application will constitute justifiable    Treasurer of State to satisfy the amount due the state of Ohio 
ground for disallowance of the claim.                             as authorized by R.C. section 5749.09. Any amount in excess  
                                                                  of such indebtedness shall be drawn payable to the applicant. 
Applications shall be fi led with the tax commissioner, on the 
form prescribed by him for such purpose, within 90 days from      The applicant must assign a claim fi le number beginning 
the date it is ascertained that the payment or assessment         with No. 1 in the space provided above so as to maintain a 
was illegal or erroneous; provided, however, that in any event    refund claim fi le number sequence for reference purposes. 
the application must be fi led within four years from the date     The claim must be sent to the Department of Taxation, Attn: 
of such illegal or erroneous payment of the tax.                  Excise Tax Section, P.O. Box 530, Columbus, OH  43216-
                                                                  0530. If you have any questions regarding this application, 
If the applicant who is entitled to a refund under R.C. section   please call (855) 466-3921. 
5749.08 is indebted to the state of Ohio for any tax payable to  
the General Revenue Fund, the amount of such indebtedness