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Get CT DRS AU-524 2017-2021

SIGNATURE OF AUTHORIZED REPRESENTATIVE DATE NAME OF AUTHORIZED REPRESENTATIVE PLEASE PRINT TITLE PLEASE PRINT THIS SCHEDULE SHALL BE ATTACHED AND MADE A PART OF SALES TAX REFUND CLAIM OF CLAIMANT AU-524 Rev. 09/17. DEPARTMENT OF REVENUE SERVICES AUDIT DIVISION 450 COLUMBUS BLVD SUITE 1 HARTFORD CONNECTICUT 06103 ASSIGNMENT OF RETAILER S RIGHTS FOR REFUND SCHEDULE NO. NAME OF CLAIMANT CT SALES TAX I. D. NAME OF RETAILER STREET ADDRESS CITY OR TOWN AND ZIP CODE TOTAL SALES TAX AMOUNT ASSIGNED FOR .

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