Fillable Printable Iowa Refund Request Form Ia 843
Fillable Printable Iowa Refund Request Form Ia 843
Iowa Refund Request Form Ia 843
22-009a (08/21/12)
www.iowa.gov/tax
Iowa Department of Revenue
IA 843 Claim for Refund
Sales, Use, Excise, and Local Option Tax
NAME
BUSINESS NAME
CURRENT MAILING ADDRESS
CITY, STATE, ZIP
SOCIAL SECURITY NUMBER SALES OR USE TAX PERMIT NUMBER
FEDERAL EMPLOYER IDENTIFICATION NUMBER COUNTY NUMBER
CHECK THE BOX corresponding to the type of refund you are claiming. Complete all sections on the form.
See instructions for documentation required to support claim.
Retail Sales Tax
Fuel Used in Implement of Husbandry
Fuel Used in Processing
Machinery, Equipment, and Computers
Retailer’s Use Tax
Consumer’s Use Tax
Vehicle One-time Registration Fee/Vehicle Use Tax:
Enter your Vehicle Identification Number (VIN):
Local Option Sales Tax: Complete the schedule on the second page.
Local Hotel / Motel Tax
Automobile Rental Tax
State Excise Tax:
Lodging
Certain Construction Equipment
CLAIM PERIOD______________TO_____________Break down claim period by quarters. Attach additional sheets if necessary.
TAX PERIODORIGINAL IOWA TAX PAID
(no local option sales tax)CORRECTED AMOUNTTAX TO BE REFUNDED
1. Column Subtotals
2. Subtotal from reverse side of Local Option Tax Refund
3. TOTAL REFUND DUE: Add subtotals.
REASON FOR REFUND REQUEST: Explain in detail the reason(s) a refund is due, including applicable Code section and rule
references. Attach an additional sheet if needed.__________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
THE IA 843 SHOULD BE THE FIRST PAGE OF A SUBMITTED CLAIM, WITH ALL SUPPORTING DOCUMENTATION BEHIND - SEE
INSTRUCTIONS FOR SUPPORTING DOCUMENTATION REQUIREMENTS.
I, the undersigned, declare under penalty of perjury that I have examined this claim, including all accompanying schedules, documentation, and
statements, and, to the best of my knowledge and belief, it is a true, correct, and complete claim.
CLAIMANT’S SIGNATURE:_________________________________DATE:______________PHONE NUMBER:__________________________
PRINT NAME:___________________________________________TITLE (IF CORPORATION):_______________________________________
Biodiesel Production
Reset Form
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Who May File
Any taxpayer who believes that an overpayment of retail sales,
retailer’s use, consumer’s use, vehicle one-time registration fee/
use tax, local option, local hotel/motel, automobile rental, or
state excise tax exists may file this Claim for Refund form.
The IA 843 may not be used to claim a refund of withholding.
Employers must file an amended withholding quarterly return to
claim a withholding tax refund.
Individuals must file the IA 1040, IA 1040A, or IA 1040X, as
appropriate, to request a refund of Iowa income tax withheld.
All claims must include a sales or use tax permit number, if
applicable.
Individuals:You must provide your Social Security Number.
Sole Proprietors: You must provide a Social Security Number
and a Federal Employer Identification Number, if applicable.
Partnerships and Corporations: You must provide your
Federal Employer Identification Number.
Who Must Sign
If a claim is filed for a corporation, the claim must be signed
either by an officer or other authorized representative of the
corporation. If an attorney or agent is filing the claim on behalf
of the claimant, a power of attorney (original) authorizing the
attorney or agent to sign must be submitted with the claim. A
power of attorney should clearly identify who is to receive the
refund check and where it should be mailed.
Supporting Documentation Required - contact the
Department if you would like to submit supporting
documentation electronically.
Retail Sales/Use Tax, Consumer’s Use Tax, Local Hotel/
Motel, State Excise, and Automobile Rental Tax: Provide
copies of the invoices, exemption certificates, credit memos,
and any other supporting documentation applicable.
Fuel Used in Processing and Implements of Husbandry:A
processing vs. nonprocessing energy study to determine the
exempt percentage, copies of all invoices, and a schedule of
energy used. Explain the manufacturing process (how the
equipment using the fuel is used in this process) and describe
the tangible personal property to be sold at retail.
22-009b (09/25/12)
Farm and Industrial Machinery and Equipment: Copies of
the invoices. Explain how each item is used directly and
primarily in your agricultural production or manufacturing
process.
Computers: Copies of all invoices. Explain how they are used
in processing or storing data and describe your type of business
or occupation.
Vehicle One-time Registration Fee (on or after 7-1-08) /
Vehicle Use Tax (prior to 7-1-08): Copies of the original bill
of sale, the title, and any additional supporting information.
NOTE: The vehicle identification number (VIN) must be
entered on the first page of this claim form.
Local Option Tax: Copies of all invoices verifying that local
option tax has been paid to the State of Iowa.
Biodiesel Production: Provide the number of biodiesel
gallons produced during each quarter.
Where is My Sales/Use Refund? Call 515/242-6034.
Questions?
Phone: 515-281-3114 or 1-800-367-3388
E-mail: [email protected]
Where to File:Compliance Division
Iowa Department of Revenue
PO Box 10456
Des Moines, IA 50306-0456
Instructions for IA 843
If this is a correction to a sales tax return, you need to file an amended return.
Computation of Local Option Sales Tax Claim Periodto
Break down the claim period by quarters. Attach an additional sheet if needed. Break down each tax period by county. Enter the
local option tax to be refunded on the front of this claim on line 2, Subtotal Local Option Tax Refund.
76-POCAHONTAS
77-POLK
78-POTTAWATTAMIE
79-POWESHIEK
80-RINGGOLD
81-SAC
82-SCOTT
83-SHELBY
84-SIOUX
85-STORY
86-TAMA
87-TAYLOR
88-UNION
89-VAN BUREN
90-WAPELLO
91-WARREN
92-WASHINGTON
93-WAYNE
94-WEBSTER
95-WINNEBAGO
96-WINNESHIEK
97-WOODBURY
98-WORTH
99-WRIGHT
01-ADAIR
02-ADAMS
03-ALLAMAKEE
04-APPANOOSE
05-AUDUBON
06-BENTON
07-BLACK HAWK
08-BOONE
09-BREMER
10-BUCHANAN
11-BUENA VISTA
12-BUTLER
13-CALHOUN
14-CARROLL
15-CASS
16-CEDAR
17-CERRO GORDO
18-CHEROKEE
19-CHICKASAW
20-CLARKE
21-CLAY
22-CLAYTON
23-CLINTON
24-CRAWFORD
25-DALLAS
51-JEFFERSON
52-JOHNSON
53-JONES
54-KEOKUK
55-KOSSUTH
56-LEE
57-LINN
58-LOUISA
59-LUCAS
60-LYON
61-MADISON
62-MAHASKA
63-MARION
64-MARSHALL
65-MILLS
66-MITCHELL
67-MONONA
68-MONROE
69-MONTGOMERY
70-MUSCATINE
71-O’BRIEN
72-OSCEOLA
73-PAGE
74-PALO ALTO
75-PLYMOUTH
26-DAVIS
27-DECATUR
28-DELAWARE
29-DES MOINES
30-DICKINSON
31-DUBUQUE
32-EMMET
33-FAYETTE
34-FLOYD
35-FRANKLIN
36-FREMONT
37-GREENE
38-GRUNDY
39-GUTHRIE
40-HAMILTON
41-HANCOCK
42-HARDIN
43-HARRISON
44-HENRY
45-HOWARD
46-HUMBOLDT
47-IDA
48-IOWA
49-JACKSON
50-JASPER
IOWA COUNTIES AND COUNTY NUMBERS
·
·
TAXCOUNTYORIGINALCORRECTEDLOCAL OPTION TAX
PERIODNUMBERTAX PAIDAMOUNTTO BE REFUNDED
TOTALS
Enter on line 2 of page 1, Subtotal
