SV 4
                                                                                                                                                           Rev. 4/08

                        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 justifi able  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