Texas Refund Form Request

Complete form below or call (855) 557-7752 to obtain an application for a refund.

An application form will by sent to you by U.S. Mail.  Incomplete   information can result in a delay in processing.

Use tab key to move from field to field.  Complete information in required (*) fields.  Click on “Submit Request” when finished.

First Name*
Last Name*
Company
Address*
City*
State*
 Zip*
Your Email
Phone*
  
Person/Company that collected assessment*