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To the buyer and the buyer should attach it to Form BCR as documentation of the refund claim. SECTION 1 BUYER INFORMATION (Buyer s Name) ( (Buyer s Address) ) (Area Code) (State) (City) 1. Period covered by this refund claim: From: (Telephone No.) (Zip) To: 2. Total state, county and stadium tax paid in error . . . . . . . . . . . . . . . . . . . . . . . . . $ (Total of Columns 7, 8, 9, and 10 from Section 3) Include this amount in the total on line 3, Form BCR.) SECTION.

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