Vermont Application for Refund of Miscellaneous Taxes

Application for Refund of Miscellaneous Taxes
Form REF-619
Vermont Department of Taxes
Phone: 802-828-2551

PO Box 547

Montpelier, VT 05601-0547

*256191100*

Application for Refund of
Miscellaneous Taxes

Vermont Form

REF-619

* 2 5 6 1 9 1 1 0 0 *

To request a refund from the following taxes - Check ONE
c Cannabis Excise
c Health Care Claims
c Captive Insurance Premium
c Health Care Contribution
c Estate
c Insurance Premium
c Fire Training
c Malt and Vinous Beverage
c Fuel
c Railroad Company
c Hazardous Waste
c Solid Waste

c Telephone Gross Receipts
c Telephone Personal Property
c Uniform Capacity
c Wind Powered

Federal ID Number

Entity (Business) Name

OR
	

Individual Last Name	

First Name	

OR

Initial

Social Security Number

Mailing Address, Line 1	

Daytime Telephone Number	

Mailing Address, Line 2 (if needed)	

Period Covered by Claim (mmddyyyy - mmddyyyy)

City	

State	

For Department Use Only

ZIP Code	

Foreign Country (if not United States)	

Email Address

Name of Representative (if any)	

Mailing Address

City	

State	

ZIP Code	

Foreign Country (if not United States)

05641 Email Address	

Daytime Telephone Number

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, this
declaration further provides under 32 V.S.A. §§ 5901-5903 that 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

Email Address (optional)

Preparer’s
Signature

Date

Preparer’s
Printed Name

Preparer’s SSN
or PTIN

Check if self-employed



Firm’s Name (or yours if self-employed) and Address
EIN

Preparer’s Telephone Number
(

Preparer’s Email Address (optional)

)

Form REF-619

5454

Page 1 of 1, Rev. 04/25

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