Date: ____________________________
Claim for tax refund is hereby made in the amount of $ _________________________.
This claim is itemized as follows:
Our reasons for ling claim are:
Name of Company _______________________________________________________________________________________________________
Street Address __________________________________________________________________________________________________________
City ______________________________________________________________State __________ Nine Digit Zip Code ____________________
Federal Identication # Permit/License # ___________________
AFFIDAVIT
I do solemnly declare and afrm under the penalties of perjury that the contents of the foregoing document are true and correct to
the best of my knowledge, information, and belief.
Signature Title
COM/ATT-001-1 01/17
MARYLAND
FORM
001-1
CLAIM FOR REFUND
Complete this Claim For Refund and send to:
Comptroller of Maryland
Revenue Administration
Alcohol and Tobacco Tax
P.O. Box 2999
Annapolis, Maryland 21404-2999
For more information, contact:
Telephone: 410-260-7312, 800-638-2937
Fax: 410-260-7924
