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For Refund or Template Form
Line ________
11. Corporate Name: _______________________________________________________________________________
12. State or Country of Incorporation: __________________________________________________________________
13. Nature of Claim:
(Mark an “X” in one box only.)
o Refund
14. Amount of Claim: $________________________________
o Adjustment of Assessment
• No refund will be made from an overpayment of less than $200.
• Any amount to be refunded will be reduced by $200.
• The $200...
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