Director's Stamp
rorm 843 (Date received)

1
(Rev. Dec. 1970) |
Department of the Treasury
Internal Revenue Service |
The Internal Revenue Service will indicate in the block below the kind of claim filed, and fill in, where required. |
(CO Refund of Taxes Illegally, Erroneously, or Excessively Collected. |
© Refund of Amount Paid for Stamps Unused, or Used in Error or Excess.
( Abatement of Tax Assessed (not applicable to income, estate or gift taxes). |

Please Type or Print Plainly _ |

Name of taxpayer or purchaser of stamps

‘Number and street - ” " City or town, State, and ZIP code

_ Fill in applicable items—Use attachi ents if necessary
a. Your social security number | Wife’s number, if joint return ‘b. Employer identification number (if any) _

i f | i i
_ Hy i I i Po _
¢. Internal Revenue Service office where re- | d. Name and address shown on return, if different from above
turn (if any) was filed

@. Period—if for tax reported on annual basis, prepare separate form for each taxable year | f. Kind of tax

From ... = or WDereeey tO
g. Amount of assessment | Dates of payment ~
Ss _ | __
h. Date stamps were purchased from Gov- | i. Amount to be refunded (If income tax, | j. Amount to be abated (not applicable to income,
ernment |" complete computation below) | estate, or gift taxes)
|
i |
|_$ i

. The claimant believes that this claim should be allowed for the following reasons:

x|

Computation of Income Tax Refund Income Tax

Tax withheld

Estimated tax paid |

Tax paid with original return

Any additional income tax paid ey >=. L

Total tax paid (add lines 1-4) - ww \

Less: Your computation of correct tax... 6 ee ee ee if
i

Amount of overpayment .

Amount previously refunded Le Co ee

Net overpayment (enter in item i above) woe .
Under penaities of perjury, | declare that | have examined this claim, including “gecompanying schedules and statements, and
to the best of my knowledge and belief it is true, correct, and complete.

CON ATAWNH

Signed ..

See instructions on reverse. Form 843 (Rev. 12-70)


Instructions

1. Form 1040X or Form 1120X may be used to amend an
individual or corporation income tax return. The Internal Rev-
enue Service prefers that they be used rather than Form 843,
since these forms are designed to expedite processing.

2. The reasons for filing this claim must be set forth in de-
tail under item k.

3. If a joint income tax return was filed for the year for which
this claim is filed, social security numbers of both husband
and wife should be entered and each must sign this claim even
though only one had income. If the taxpayer has been assigned
an employer identification number, it also must be entered.

4. The claim may be made by an agent of the taxpayer,
but the original or a true copy of a power of attorney must
accompany the claim.

5. If a return is filed by an individual and a refund claim is
thereafter filed by a legal representative of the deceased, certi-
fied copies of the letters testamentary, letters of administration,
or similar evidence must be attached to the claim, to show the
authority of the executor, administrator, or other fiduciary by
whom the claim is filed. If an executor, administrator, guardian,
trustee, receiver, or other fiduciary files a return and thereafter
a refund claim is filed by the same fiduciary, documentary evi-
dence to establish the legal authority of the fiduciary need not
accompany the claim, provided a statement is made on the
claim showing that the return was filed by the fiduciary and
that the latter is still acting.

6. Where the taxpayer is a corporation, the officer having
authority to sign for the corporation should place his signature
and title on this claim.

7. If a claim is for excess social security (FICA) tax with-
held as a result of having more than one employer during a
calendar year, include the names and addresses of your em-
ployers, and the amount of wages received and FICA employee
tax withheld by each, as part of your explanation in item k.
Do not claim tax withheld if you have claimed the excess with-
holding on your individual income tax return.

Where to File

Certain claims relating to alcohol and tobacco taxes should
be filed with the Assistant Regional Commissioner (Alcohol and
Tobacco Tax). See the regulations pertaining to the particular
alcoho! or tobacco tax. Otherwise,

If your legal residence or principal
place of business is in this State

Vv

Delaware, District of Columbia, Mary-

Use this mailing address
—. ’

Internal Revenue Service Center

land, New Jersey, Pennsylvania, 11601 Roosevelt Boulevard
Virginia Philadelphia, Pa. 19155
Alabama, orgia, Missis- Internal Revenue Service Center

Geor
Sleek North Carolina, South Carolina,
Tennessee

4800 Buford Highway
Chamblee, Georgia 30006

indiana, Kentucky, Michigan, Ohio,
West Virginia

Internal Revenue Service Center
Cincinnati, Ohio 45298

Arkansas, Colorado, Kansas, Louis
ana, New Mexico, Oklahoma, Texas,
Wyoming

Internal Revenue Service Center
3651 S. Interregional Highway
Austin, Texas 78740

Alaska, Arizona, California, Hawaii,
Idaho,’ Montana, Nevada,’ Oregon,
Utah, Washington

Internal Revenue Service Center
1160 West 1200 South Street
Ogden, Utah 8440:

lows, Minnesota, Missouri,
Nebraska North Bakotay’ South
kota, Wisconsi

Internal Revenue sevice Center
2306 E. Bannister Roai
Kansas City, Missouri 64170

Connecticut, Maine, Massachusetts,
New Hampshire, New York, Rhode
Island, Vermont

If you are located,
Panama Canal Zone, American
Samoa, Guam

Puerto Rico (or if excluding income
under section 933)

Virgin Islands:

permanent residents

Internal Revenue Service Center
310 Lowell Street
Andover, Mass. 01812

"Use this address

Internal Revenue Service Center
11601 Roosevelt Boulevard

_ Philadelphia, Pa, 19155

Internal Revenue Senice Center
11601 Roosevelt Boulevard
Philadelphia, Pa. 19155

Virgin islands:
Permanent residents

ance,

Department of
Tax Division
Charlotte Amalie,
homas,
Virgin Islands 00801

U.S. citizens with foreign addresses (except A.P.O. and F.P.0.) and
those excluding income under sec. 911 or 931 and corporations having
a principal place of business outside the United States file with the
Internal Revenue Service Center, 11601 Roosevelt Boulevard, Philadel-

phia, Pennsylvania 19155.

FOR INTERNAL REVENUE SERVICE USE ONLY

Transcript of Claimant’s Account
(Complete only as to miscellaneous excise taxes and alcohol, tobacco, and certain

other excise taxes imposed under subtitles D and E,

Internal Revenue Code.)

The following is a transcript of the record of this office covering the liability that is the subject of this claim.

A—Assessed Taxes

Taxable Period j Paid, Abated, or Credited ]
and Class | Document Reference | Amount Date op Pn BE
of Tax Locator No. and Date | Assessed + gpate oF | Amount i ape cr.| Remarks
—@ | | | _@ | ow |
| | |
| | |
| Li}
if | i |
| \
iT |
| | |_|
B—Purchase of Stamps
| |
To Whom Sold or Issued | Kind | Number | Denon | Period
| Commencing
@_ | 0) | w 0) ©)
|
] | ~
Prepared by (initials) Date =