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Form BOE-101 Fillable Claim for Refund
(all forms fillable on Windows, Mac, Android tablets, and iPad using Adobe Reader XI)(and paid) (BUSINESS NAME) (CLEAR) CLEAR (CONTACT PERSON (if other than signatory)) (DATE SIGNED) (Determination(s) dated ) (Determination(s) dated and paid; Return(s) filed for the period to) (For more information concerning the refund and appeals process see publication 17 Appeals Procedures:Sales and Use Taxes and (GENERAL PARTNER (if applicable)) (Instructions on back) (may be left blank) or such other amounts as (NAME OF TAXPAYER(S) OR FEEPAYER(S)) (Other (describe fully)) (Other (please specify the applicable tax law or fee program)) (please specify the applicable tax law or fee program) (postmark) or the date that you personally deliver your claim to your nearest BOE office This date may differ from the date signed (PRINT NAME OF SIGNATORY) (PRINT) PRINT (Return(s) filed for the period to) (Sticky Note comment Return Address (TAXPAYER'S OR FEEPAYER'S ACCOUNT NO ) (TAXPAYER'S OR FEEPAYER'S SOCIAL SECURITY NUMBER(S)* OR FEDERAL EMPLOYER IDENTIFICATION NUMBER) (TELEPHONE NUMBER ( AREA CODE )) (TELEPHONE NUMBER) (The overpayment described above was caused by ) (the undersigned hereby makes claim for refund or credit of $ (may be left blank) or such other amounts as may be established in tax interest and penalty in connection with:) (TITLE OR POSITION OF CONTACT PERSON) (TITLE OR POSITION) *See BOE 324 GEN Privacy Notice regarding disclosure of the applicable social security number *The time period for filing a claim for refund will vary depending on a number of factors particularly the cause of overpayment and 7/24/2003 1:57:04 PM According to amount at the time of submitting the claim either enter $1 in the space provided or leave that space empty The supporting documenta and paid and the business s name (dba) is XYZ Auto Repair XYZ Auto Repair should be entered at www boe ca gov or call our Information Center at 800 400 7115 BOE 101 (BACK) REV 7 (11 09) BOE 101 (FRONT) REV 7 (11 09) bookkeeper then he or she should enter Bookkeeper in the space provided BUSINESS NAME Business Name:The name of the business should be entered in the space provided For example if the claimant s name is John Doe Case ID No cessing your claim for refund should a BOE representative have questions about your claim Chapter 6 Article 1 of the California Use Fuel Tax Law or Chapter 7 Article 1 of the California Sales and Use Tax Law and where applicable Uniform Chapter 8 Article 1 and 2 of the Diesel Fuel Tax Law checked to indicate the return filing period the determination date or other time period The period of time covered should be entered in CLAIM FOR REFUND OR CREDIT claimforrefundshouldbeentered Thebusinessname(dba)shouldnotbeenteredunlessitisalsothenamethatisregisteredwith CONTACT PERSON (if other than signatory) Contact Person (if other than signatory):This line may be used to designate a person (other than the signatory) to contact should Credit interest is available under certain circumstances If you would like to be considered for credit interest please check here Date Signed:The date the claim form is signed must be entered in the space provided designated by the taxpayer or feepayer Determination(s) dated documentationtosupportaclaimforrefundshouldbeprovidedwithin30daysoftheacknowledgementbytheBOEofyourrefundclaim enteredinthespaceprovided IftheclaimantisnotregisteredwiththeBOE thename(s)shownonthedocumentsthatsupportthe FOR BOEUSE ONLY husbandandwife thesocialsecuritynumberoftheindividualorboththehusbandandwifeshouldbeentered Iftheclaimantisa instanceswherearefundorportionthereofmaybedisclosedtotheInternalRevenueService Iftheclaimantisanindividualora INSTRUCTIONS FOR COMPLETING CLAIM FOR REFUND is attached keeper accountant taxpayer etc EvenifthepreparerisnotregisteredwiththeBOE thepreparerisgenerallynotrequiredtobeacorpo Local Sales and Use Tax Ordinances and the Transit District Transactions (Sales) and Use may be established in tax interest and penalty in connection with: mustbeprovided NAME OF TAXPAYER(S) OR FEEPAYER(S) of limitations is established by the filing date of your claim for refund The filing date of your claim is generally the date of mailing of overpayment fully explain the circumstances in the space provided If your claim represents a partial payment or installment payment on a determination or other liability please submit a separate claim for each future payment for which you plan to file a claim for refund or feepayer s behalf The preparer must also include his or her title or position in the space provided For example if the preparer is the Other Other (describe fully) overpayment Please include your documentation with your claim for refund or credit or if the documentation is extensive please have it P O Box 942879 partnership thesocialsecuritynumber(s)ofthegeneralpartner(s)andthepartner sname(s)shouldbeenteredinthespacepro PRINT NAME OF SIGNATORY rateofficerortohavepowerofattorney However thepreparermustbeauthorizedbythetaxorfeepayertofiletheclaimonthetaxpayer readily available upon request Refund Section MIC:39 remembertoprovidethedateshownonthenoticeofdeterminationandthedatetheliabilitywaspaid Iftheclaimrepresentsanothertype Return(s) filed for the period Sacramento CA 94279 0039) securitynumber(s)isrequired(seeBOE 324 GEN PrivacyNotice)eveniftheclaimantisnotregisteredwiththeBOEasthereare SignatureandTitleorPosition:Theprepareroftheclaimformmustsignhisorhernameinthisspace Thepreparermaybethebook SIGNED BY DATE SIGNED Special Taxes and publication 117 Filing a Claim for Refund ) specific tax or fee for which you are filing a claim State Board of Equalization STATEOFCALIFORNIABOARD OF EQUALIZATION Supporting Documentation: Tax Ordinances or TAXPAYER S OR FEEPAYER S ACCOUNT NO GENERAL PARTNER (if applicable) TAXPAYER S OR FEEPAYER S SOCIAL SECURITY NUMBER(S)* OR FEDERAL EMPLOYER IDENTIFICATION NUMBER Taxpayer sorFeepayer sSocialSecurityNumber/FederalEmployerIdentificationNumber:Disclosureoftheapplicablesocial TaxpayerorFeepayerNameandAccountNumber:Thename(s)andaccountnumberasregisteredwiththeBOEshouldbe TELEPHONE NUMBER Telephone Number:Please include the telephone number of the claimant (and contact person if applicable) This will save time in pro The overpayment described above was caused by the space provided (for example January 1 2003 to December 31 2005) If the claim results from an audit or other such determination the type of tax or fee program for which you are filing a claim for refund Please check the appropriate laws and regulations for the the undersigned hereby makes claim for refund or credit of $ theBOE theBOEhavequestionsorrequireadditionalinformation Suchpersonsmaybeemployees consultants accountants attorneys etc as tion for the claim for refund will normally provide the necessary information for the calculation of the refund or credit due Generally the TITLE OR POSITION TITLE OR POSITION OF CONTACT PERSON vide documentation that supports the refund or credit request The documentation should be sufficient in detail and provide proof of the vided Iftheclaimantisacorporation(includingapartnershipconsistingofcorporations) thefederalemployeridentificationnumber When submitting a claim for refund you must provide the specific grounds upon which the claim is founded In addition you must pro will be provided upon request You can state the amount of the claimed overpayment including interest and penalty on the claim form If you are not sure of the actual You must file the claim within the statute of limitations for the tax/fee program for which the claim is filed* The appropriate box should be YoumayalsocontacttheBOEheadquartersunitordistrictofficeresponsibleforyourtaxorfeeaccount Compliancewiththestatute YoumayfileaclaimforrefundwithanyBOEoffice ForalistofBOEoffices orforassistancecompletingthisform pleasevisitourwebsite