Indiana Business Tax Claim for Refund

Business Tax Claim for Refund
Form GA-110L 
Indiana Department of Revenue

Form

GA-110L

Claim for Refund

State Form 615
(R18 / 8-22)

□ POA-1 form Included

Name of Taxpayer

Taxpayer Identification Number (include 3 digit location)

Address

Federal Identification Number

City

State

ZIP

Social Security Number

Indicate only one tax type from one of the following sections:
Section A – The GA110L is not to be used for Withholding, Individual, or Corporate Income tax. See instructions.

□ County Innkeepers	 □ Food & Beverage	 □ Motor Vehicle Rental	 □ Sales & Use (Not Fuel Related)	 □ VSE-103
□ Sales & Use (Utilities)	 □ Collection Fees/Penalty	 □ HRT-103	 □ Other _______________________

Section B

□ Aviation Fuel Excise	 □ Gasoline Use	 □ Oil Inspection Fee 	 □ Sales (Diesel)	
□ Surcharge (Special Fuel - see instructions) 	 □ Other Fuel Related ___________________	
Section C

□ Aeronautics	
Section D

□ BAS	

□ Cigarette Excise	

□ IFTA 	

□ Alcohol Excise	

□ Other Tobacco Products Excise	

□ IRP/BPR 	 □ Motor Carrier Fuel Tax	 □ Oversize/Overweight	 □ UCR	

Provide the explanation as to why a refund is due:

Year or Period Ending Requested Refund
(mm/dd/yyyy)
Amount

Date(s) of Tax
Payment(s)

Year or Period Ending
(mm/dd/yyyy)

Requested Refund
Amount

Date(s) of Tax
Payment(s)

I hereby certify that the foregoing account is just and correct; that the amount claimed is legally due, after allowing all just credits; and
that no part of the same has been paid. I further understand that this refund may be applied to any liability which I currently have outstanding. Under penalties of perjury, I declare that I have examined this form, including the accompanying schedules and statements,
and to the best of my knowledge and belief it is true, correct, and complete.
Sign Form GA-110L and include evidence to support your claim. Failure to attach ALL documentation with your claim may result in your
claim being rejected or denied.
Signature:_______________________________ Printed Name:__________________________

Title:_______________________

Daytime Phone Number:____________________ Email:_________________________________

Date:______________________

For Department Use Only
Tax Analyst/Auditor:________________________ Date:_____________ Supervisor:_____________________ Date:_____________
Claim Number:____________________
Year

Interest
Paid
From

Interest
Paid
To

Total
Interest
Amount

Total
Refund
Amount

DLN

Instructions for Completing Form GA-110L
Complete a separate Form GA-110L for each tax type and location. Fill-in all blanks as any missing or incomplete information may delay the
processing of your Claim for Refund or may cause the Claim for Refund to be rejected or denied. Make sure any and all returns have been filed.
Note: Claim for Refund (Form GA-110L) can be completed electronically via the Indiana Department of Revenue’s (DOR) secure e-service portal, the
Indiana Taxpayer Information Management Engine (INTIME), at intime.dor.in.gov.
As of Dec. 1, 2020, DOR no longer accepts any removable media to include CDs, DVDs, or USB flash drives from customers needing to
submit documents. Any media received in this manner will be returned or destroyed. Customers should use INTIME to submit data and
documents in a secure, quick, and efficient manner.
DOR will not accept protective claims submitted at the end of the calendar year. All supporting documentation must be submitted with the GA-110L
claim.

	
	
	
	
	
	
	

• Include the taxpayer’s name, address, and correct Taxpayer Identification Number (TIN) with location number that was assigned by the state for 		
your specific location.
•

Check only ONE Tax Type.
o
Each tax type requires a separate GA-110L.
o
Refunds of the Surcharge tax are available to non-motor carriers who purchased special fuel (diesel, biodiesel, compressed natural 		
gas or liquified natural gas) in Indiana from July 1, 2017 through June 30, 2018. The vehicle make, model and Vehicle Identification 		
Number (VIN) must be included, along with purchase receipts.
o
This form is not to be used for Withholding, Individual, or Corporate Income tax. Refunds for these tax types must be requested with
the appropriate amended return. All amended WH-3’s must include corrected wage statements as well.

•

Include a complete explanation of why the refund is due. Attach ALL evidence to support your claim. Examples are not all inclusive: invoices 	 	
showing tax paid; copy of exemption certificate if it is an exempt customer; purchase agreement and contract for items such as software 		
and warranties; proof of payment (credit invoice or canceled checks); utility bills showing meter number; use tax journal and any additional 		
documentation to support your claim. Failure to attach ALL documentation with your claim may result in your claim being rejected or denied.
Do not use removable media (CDs, DVDs, or USB flash drives) to submit documents. Any media received in this manner will be 		
returned or destroyed.

•

For a refund claim to be valid, a refund amount must be a request for the amount legally due for a specific tax period. Refund claim amounts 		
must be separately stated by period or tax year. Include each requested refund amount for the appropriate period(s).

•

Be sure to sign the GA-110L form and include a daytime phone number and email address. The form must be signed to be a valid refund claim. 		
Including a correct email address will help expedite the refund process.

•

Complete and attach a Power of Attorney (POA-1) form authorizing DOR to discuss your claim and specific tax type with someone other than 		
the taxpayer. An electronic POA (ePOA) can be completed via DOR’s secure e-service portal INTIME at intime.dor.in.gov.

Allow 60 days for processing before contacting DOR regarding the status of your claim.
For a refund to be valid, it must include:
1.	
the refund amount;
2.	
the tax period for which the refund is due;
3.	
the reason for the refund;
4.	
the taxpayer’s signature; and
5.	
all required supporting documentation
If your claim does not include these items, it will be rejected or denied.

Mailing/Contact Information
Please use the information below based on the tax type selected.
Section A

Section B

Section C

Section D

Indiana Dept. of Revenue
P.O. Box 935
Indianapolis, IN 46206-0935

Indiana Dept. of Revenue
P.O. Box 1971
Indianapolis, IN 46206-1971

Indiana Dept. of Revenue
P.O. Box 901
Indianapolis, IN 46206-0901

Indiana Dept. of Revenue
P.O. Box 6075
Indianapolis, IN 46206-6075

(317) 232-2240

(317) 615-2630
[email protected]

(317) 615-2710
[email protected]

(317) 615-7200
[email protected]