COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF STATE Corporation Bureau 401 North Street, Room 206 PO Box 8722 Harrisburg, PA 17105-8722 Telephone: 717-772-2708 Fax: 717-783-2244 Website: www.dos.state.pa.us/corp Email: [email protected]
PETITION FOR REFUND(Rev. 7/2003)
1. Name of Petitioner: _____________________________________________________________________ _______________________________________________________________________________________ 2. Taxpayer ID (FEIN or SSN): ________________________________________ 3. Address:_______________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ 3. Phone Number:__________________________________________________________________________ 4. Amount to be refunded: $______________________ 5. Client/Request Name: ________________________________________________
PLEASE RETURN A COPY OF THE FRONT AND BACK OF YOUR CANCELLED CHECK, ALONG WITH THE ORIGINAL NOTIFICATION OF THE AMOUNT TO BE REFUNDED TO THE ATTENTION OF THE CORPORATION BUREAU REVENUE CLERK AT THE ABOVE ADDRESS.
This Document does not serve as ORIGINAL NOTIFICATION **This is an internal document**