New York State Department of Taxation and Finance
                                                                                                                                             AU-11 
                                    Application for Credit or Refund                                                                                (12/10)
                                    of Sales or Use Tax

• Do not use this form to apply for a Qualified Empire Zone Enterprise (QEZE) refund or credit for purchases made on or after 
  September 1, 2009. Use Form AU-12, Application for Credit or Refund of Sales or Use Tax - Qualified Empire Zone Enterprise 
  (QEZE).
• Do not use this form to apply for a refund of tax paid on qualifying purchases of motor fuel or diesel motor fuel. Use Form FT-500, 
  Application for Refund of Sales Tax Paid on Automotive Fuels.
Read Form AU-11-I, Instructions for Form AU-11, before completing this application.
Applicant information (Please type or print legibly)
Name (Legal business name, including DBA or individual)             Telephone number                  NYS Sales Tax ID number (if registered) or EIN or social security number
                                                                    (    )
Mailing address (number and street or rural route)                                                    Period covered by claim (date(s) of purchase) (mm/dd/yyyy)
                                                                                                                                 -
City                                                                State   ZIP code                  Refund claimed
                                                                                                      $
Representative’s name (if any); see instructions                    Telephone number                  Credit claimed
                                                                    (    )                            $
Representative’s mailing address (number and street or rural route)                                   If credit shown above has already been claimed on a
                                                                                                      sales tax return, enter the period covered by the                        
                                                                                                      quarterly or annual return (mm/dd/yyyy).
City                                                                State   ZIP code
                                                                                                                                 -

Explanation of your claim:

•  Include copies of all supporting documents (see instructions).
•  Use additional sheets, if necessary. Make sure your name and ID number are on each sheet.
•  We can’t process applications that aren’t signed, don’t include supporting documents, or that are in any other way incomplete. 

Certification: I,                                                   , the applicant named above, or partner, officer, or other authorized representative 
of such applicant, do hereby:
•   make application for credit and/or refund of tax, pursuant to the New York State Tax Law; and 
•   certify that the above statements, and any documents provided to substantiate the credit or refund claimed, are true, complete and
   correct and that no material information has been omitted; and
•   certify that all of the tax for which this claim is filed has been paid, and no portion has been previously credited or refunded to the  
  applicant by any person required to collect tax; or, if the claim for credit or refund is made by a person required to collect tax, that 
  the amount claimed has previously been refunded to the appropriate purchaser; and
•   certify that no amount claimed has previously been subject to a credit or refund; and
•   make these statements with the knowledge that willfully providing false or fraudulent information with this document with the intent 
  to evade tax may constitute a felony or other crime under New York State Law, punishable by a substantial fine and a possible jail 
  sentence; and
•   understand that the Tax Department is authorized to investigate the validity of the credit or refund claimed and the accuracy of any 
  information provided with this claim.
Applicant’s signature                                                      Applicant’s title                                                 Date

Representative’s signature (if any)                                        Representative’s ID number                                        Date