Vermont Application for Refund of Miscellaneous Taxes

Application for Refund of Miscellaneous Taxes
Form REF-619
FORM REF-619 Instructions
Application for Refund of Miscellaneous Taxes
General Information
Please print in BLUE or BLACK ink only.
PURPOSE OF APPLICATION FOR REFUND
Use Form REF-619 to request a refund for the miscellaneous tax types listed on the form.
Do not use this form to request a refund resulting from correction of errors on a return. If you want
to correct errors on a return, you must submit an amended return.
TAX TYPES INCLUDED
This form may be used for any of the tax types listed on the form itself. Tax types not listed have
their own specifically-designed requests for refund.
Please check the appropriate box to indicate the tax type for which the refund is requested.
EXPLANATION AND DOCUMENTATION
Please give a full explanation of the circumstances surrounding the request for refund in the space
provided. Attach additional sheets as necessary. Also submit any documentation that would help
an examiner understand the basis for your request.

Form REF-619 Instructions
Page 1 of 1
10/17

Vermont Department of Taxes
Phone: (802) 828-2551

VT Form

REF-619

PO Box 547

Montpelier, VT 05601-0547

*176191100*

Application for Refund of
Miscellaneous Taxes

* 1 7 6 1 9 1 1 0 0 *

To request a refund from the following taxes - Check ONE
c Captive Insurance Premium
c Health Care Contribution
c Estate
c Insurance Premium
c Fire Training
c Land Use Change
c Fuel
c Malt and Vinous Beverage
c Hazardous Waste
c Railroad Company
c Health Care Claims
c Solar Energy Capacity
	

OR
	

c Solid Waste
c Surplus Lines
c Telephone Gross Receipts
c Telephone Personal Property
c Wind Powered

Business Name					
Individual Last Name	

First Name	

OR

MI

Address			
City	

State	

Federal ID Number
Social Security Number

Telephone Number

ZIP Code	

Period Covered by Claim (mm/dd/yyyy - mm/dd/yyyy)

Foreign Country (if not United States)	

-

E-mail Address

Name of Representative (if any)			

Telephone Number

Address	

State	

City		

ZIP Code

E-mail Address

	

Refund Amount. . . . . . . $ ___________________ .____
Give a full explanation below (see instructions). Use additional sheets, if necessary, and submit all documents needed to properly substantiate your claim.

I declare under the penalties of perjury, this return is true, correct, and complete to the best of my knowledge. If prepared by a person other than the taxpayer, his/her
declaration further provides under 32 V.S.A. §§ 5901-5903 this information has not been and will not be used for any other purpose or made available to any other
person other than for the preparation of this return unless a separate valid consent form is signed by the taxpayer and retained by the preparer.
Signature of Responsible Officer

Date

Printed name

Paid
Preparer’s
Use Only

Daytime telephone
number (optional)
(
)

May the Dept. of Taxes discuss this
return with the preparer shown?

 Yes

 No

E-mail address (optional)
Preparer’s
signature

Date

Preparer’s
printed name

Preparer’s Social
Security No. or PTIN

Check if self-employed



Firm’s name (or yours if self-employed) and address
EIN

Preparer’s Telephone Number
(

Preparer’s e-mail address (optional)

)

Form REF-619

5454

10/17

Clear ALL fields

Save and go to Important Printing Instructions

Save and Print