REPORT OF DEBTS Pursuant to Tennessee Code Annotated §§ 67-1-1802 and 67-1-1808, if you are seeking a refund of $200.00 or more you are required to complete and attach this report to your claim for refund. Make a “X” in the “Yes” box if you owe any of the debts listed below to any state agency, department, bureau, commission or other state authority (“claimant”). For each debt that you report, attach documentation identifying the claimant to whom you owe the debt and the outstanding balance of such debt as of the date you submit the refund claim. If your refund claim is approved, any or all of your refund payment will be subject to offset and reduced by the amount of any debt owed. If you do not owe any of the debts listed below to a claimant, make a “X” in the “No” box. After completion, please read the paragraphs below and provide a signature and date on the lines provided. Any person who, with intent to deceive, provides false information on this report is guilty of the Class A misdemeanor offense of perjury. Yes No State tax liabilities; Yes No Child support; Yes No Overpayment of unemployment compensation benefits; Yes No Overpayment of medical assistance benefits owed the bureau of TennCare; Yes No Student loan or other obligation due to the Tennessee student assistance corporation; Yes No Fees, costs or restitution owed to a clerk who serves a court of criminal jurisdiction; Yes No Costs of incarceration; Yes No Judgments or liens in favor of a state agency, department, commission, or bureau; Yes No Any other debt owed to any other claimant. I certify that the foregoing report is true and correct to the best of my knowledge and understanding. I further acknowledge that providing false information on this report constitutes the offense of perjury under Tennessee Code Annotated § 39-16-702 and is punishable under the laws of the state of Tennessee. Signature of Taxpayer, Officer or Authorized Representative: Date:
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