State of New Jersey
DIVISION OF TAXATION
CLAIM FOR REFUND OF
PAID AUDIT ASSESSMENT
For Official Use Only
File this claim with:
Division of Taxation
Attn: Audit Claims Processing
PO Box 275
Trenton, NJ 08695-0275
PLEASE PRINT OR TYPE THE REQUESTED INFORMATION. (See instructions on reverse side.)
Federal Identification No. OR Social Security No.
Name of Taxpayer
Trade Name (if different from legal name)
Address (number and street)
City State Zip Code
1. A separate form must be completed for each tax. Check the one bo
x below that indicates the tax audited and paid, upon which
this claim is based
Corporation Business Tax
Gross Income Tax
Petroleum Products Gross Receipts Tax
Sales and Use Tax
Tobacco & Nicotine Products Wholesale Sales & Use Tax
Transfer Inheritance Tax
2. Tax Period(s) included in this claim
3. Date of Audit Assessment
Submit a copy of the Audit Assessment Notice
4. Date of expiration of Protest/Appeal Period
5. Was a protest/appeal filed on this tax assessment? Yes No
If yes, you are not eligible to file a refund claim. Only taxpayers who have paid an assessed deficiency within one year after the
expiration of the period allowed for filing a protest, and who have NOT protested or appealed that assessment, may file a claim for
refund. N.J.S.A. 54:49-14.
6. Was the assessment paid in full including penalty and interest? Yes
Date of Payment . Submit a copy of the canceled check that paid the assessment. If the check also includes payments
for other taxes, submit a schedule listing the taxes, tax periods and dollar amounts totaling the check amount.
7. Was an abatement granted? Yes
If an abatement of penalty was granted taxpayer is NOT eligible to file A-1730. N.J.A.C. 18:2-5.5(c)1.ii
8. Amount of Refund Claim $
A detailed explanation of the Claim must be attached to this form with the supporting documents
to substantiate the claim. Issues are limited to those on the deficiency tax assessment and shall
not include any additional issues with respect to the original assessment of tax.
9. Appointment of Taxpayer Representative. Is an Appointment of Taxpayer Representative necessary?
No If yes, provide a copy of the Appointment of Taxpayer Representative with this claim form.
Under penalties of perjury, I declare that I have examined this claim, including all accompanying schedules and statements, and to the best of my
knowledge and belief, it is true, correct and complete. Declaration of preparer is based on all information of which preparer has any knowledge.
Signature of Claimant/Preparer Date
If the preparer of this claim has been paid, indicate the firm’s name, address, the firm’s Federal EIN and the preparer’s Social Security Number,
Federal Identification Number or Federal Preparer Tax identification Number.
Firm’s Name Preparer’s SS# or Federal PTIN
Firm’s Address Preparer’s Federal EIN