- Any taxpayer requesting a refund in the amount of two hundred dollars ($200) or more that is not eligible for automatic credit or refund pursuant to subdivision (a)(1)(A) shall complete and submit a written report of debts owed to a claimant as defined in § 67-1-1808 on a form prescribed by the commissioner to accompany the claim for refund. If a debt is reported and if the claim for refund is approved, any or all of the refund amount shall be subject to offset to recover the amount of such debt, subject to the requirements of § 67-1-1808. Any person who, with intent to deceive, provides false information on such report commits the Class A misdemeanor offense of perjury pursuant to § 39-16-702. Such report shall state whether or not such person owes or does not owe any of the following debts as of the date of the claim:
- State tax liabilities;
- Child support;
- Overpayment of unemployment compensation benefits;
- Overpayment of medical assistance benefits owed the bureau of TennCare;
- Student loan or other obligation due to the Tennessee student assistance corporation;
- Fees, costs or restitution owed to a clerk who serves a court of criminal jurisdiction;
- Costs of incarceration;
- Judgments or liens in favor of a state agency, department, commission, or bureau;
- All other debts owed to any other claimant.
- Each of the debts in subdivision (a)(1)(B)(i) that are listed in the report shall be preceded by the words “Yes” and “No” and a taxpayer shall make a cross mark (X) or other similar mark opposite the debt the taxpayer owes or does not owe. If a taxpayer marks “Yes” for any such debt, the taxpayer shall attach documentation identifying the claimant to whom the debt is owed and the outstanding balance of the debt. The report shall clearly state in bold face type that a person who, with intent to deceive, provides false information on the report is guilty of the Class A misdemeanor offense of perjury. The report required by this subdivision (a)(1)(B) shall be made on a paper writing in substantially the following form:
REPORT OF DEBTS Pursuant to Tennessee Code Annotated §§67-1-1802 and67-1-1808, 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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