Claimant's name:

Address:

Sales tax permit #:

Or Social Security #:

I hereby swear and affirm that I have sustained actual damages in the amount of $________ as a result of a collection activity of the Department of Finance and administration and request reimbursement. The facts upon which my claim is based are as follows:

I responded to the following contacts by the Revenue Department and provided the requested information sufficient to establish my position as follows:

CLAIMANT