North Dakota Office of State Tax Commissioner
Claim for Refund
Local Sales Tax Paid Beyond Maximum Tax                                                                 For Office Use Only
(not to be used for incentive exemptions or to amend a sales tax return)
     Attach supporting documents                                                                        Acct . # _______________________
     Read instructions
Name                                                         Social Security Number or Federal Employer Identification Number

Address

City                                                         State                                      Zip Code

To obtain a refund of city or county sales and use taxes, list qualifying purchases on which you have remitted payment
to the seller.  To qualify, the local tax paid on each purchase must be in excess of the defined city or county maximum tax.
A claim for refund must be postmarked no later than three years from the date of  the invoice.  See instructions on back.

Note:  Enter one invoice per line.  Copies of all invoice(s) must be provided with refund claim.
INVOICE      INVOICE                    SELLER'S             INVOICE                                    INVOICE     SELLER'S
DATE         NUMBER                     NAME                 DATE                                       NUMBER             NAME

If you have additional transactions to report, list on separate schedule and attach to Claim for Refund.
Copies of all invoices must accompany your request.  Questions regarding the refund of tax may be directed to the Sales &
Special Taxes at 701.328.1246 or salestax@nd.gov.
Under penalties of law, I declare that the amount of city or county sales or use tax for which I am submitting this claim for refund has
NOT been refunded or credited to me by the Office of State Tax Commissioner or the seller to whom the tax was previously paid.  If a
duplicate payment is received, I will immediately send payment for such duplicate payment to the North Dakota Office of State Tax
Commissioner.

Taxpayer Signature                                      Date                                            Phone Number
Mail To:  North Dakota Office of State Tax Commissioner                 Contact:  Phone:  701.328.1246
                 Sales & Special Taxes                                                  E-mail: salestax@nd.gov
                 600 E. Boulevard Ave. Dept. 127                                        Web site: www.nd.gov/tax
                 Bismarck, ND 58505-0599
21944                                   For Privacy Statement, please see Page 2 of instructions.
(Form revised 01/16)