200961
Political Contribution Refund Application 2009
for a refund of contributions to Minnesota political parties and candidates for Minnesota state offices
Your first name and initial Last name Date of birth Social Security number
Print or type
Spouse’s first name and initial (if this is a joint return) Last name Date of birth Social Security number
Present home address (street, apartment, route)
City State Zip code How many Minnesota receipt forms (EP-3)
are you attaching to this application?
Check one box (married couples: see the notice below):
 Single Married, filing joint application Married, filing separate application
You may file only one application each year. You cannot file another application for
the same year or amend an application after it has been filed.
1 Add all the contributions made in 2009 shown on the Form(s) EP-3, Minnesota
Determining your refund
Political Contribution Receipt, attached to this application and enter the total . . . . . . . . . . . . . . 1
2 If you are a married couple filing a joint application, enter $100 . If you are
single or married but filing a separate application, enter $50 . . . . . . . . . . . . . . . . . . . . . . . . . . 2
3 Enter the amount from line 1 or line 2 above, whichever is less.
This is the amount of the refund you will receive . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
4 For direct deposit of the full refund amount on line 3, enter all of the following .
Type of account: Routing number:
Checking Savings Account number:
Sign here
I declare that this form is correct and complete to the best of my knowledge and belief.
Your signature Spouse’s signature (if a joint application) Date Daytime phone
Be sure to include the original Minnesota Political Contribution Receipt, Form EP-3, for all your contributions made in 2009
with Form PCR. DO NOT STAPLE.
Additional information
MARRIED COUPLES:
• You must choose to file either a joint application or separate applications;
you cannot file both.
• If you file a separate application, do not enter your spouse’s name and Social
Security number and do NOT have your spouse sign your application.
Mail this application no later than April 15, 2010, to:
Minnesota Revenue
Political Contribution Refund
St . Paul, MN 55146-1800
Stock No . 1009600

Form PCR instructions for 2009
Purpose of this form Include EP-3 forms Line instructions
Minnesota voters who contributed gifts of To receive your refund, you must include Line 1
money to candidates for state office or to with your Form PCR the original Minneso- Add the amounts shown on all of your
a state political party may be able to apply ta Political Contribution Receipt, Form EP-3, receipts (Form EP-3), and enter the total on
for a refund of all or a portion of contribu- you received for each contribution. Please line 1. The receipts must be for contributions
tions made during the calendar year. The do not staple your receipt to the form. If made in 2009.
maximum refund is $50 for an individual you do not include the original receipts,
Line 2
and $100 for a married couple. your form will be sent back to you. Your
Enter $100 if you are filing a joint applica-
contributions must have been made in 2009
An individual or married couple filing a
tion. If you are single or married and filing a
to file the 2009 Form PCR.
joint application may file only one Form
separate application, enter $50.
When to file
PCR for each calendar year in which
Line 3
contributions were made, even if they You may apply for your refund at any time,
contributed to more than one candidate Enter the amount from line 1 or line 2,
but no later than April 15, 2010.
or party. whichever is less.
Do not mail your application in the same
You may receive a refund for all or a por- You will receive the total of your contribu-
envelope with your Minnesota income tax
tion of contributions you made in 2009 to tions up to the maximum refund, which is
return. The amount of your political con-
candidates for the following Minnesota state $100 if you are married filing a joint applica-
tribution refund cannot be used as a credit
offices—if the candidates have signed an tion or $50 if you are single or married filing
on your Form M1. Putting Form PCR in the
agreement with the Minnesota Campaign a separate application.
same envelope with your return may delay
Finance and Public Disclosure Board to ob- processing of both forms.
Use of information
serve the state campaign spending limit law:
Amended returns, extensions for fil- Form PCR is not required by law to be filed.
• Minnesota House of Representatives
ing are not permitted However, to claim a political contribution
• Minnesota State Senate refund, you mut file this form. All informa-
Form PCR cannot be amended.
• Governor and Lieutenant Governor of tion on this form is required to properly
Minnesota You cannot get an extension to file Form identify you and determine if you qualify for
• Attorney General of Minnesota PCR. It must be filed by the April 15, 2010, this refund. Your Social Security number is
• Secretary of State of Minnesota due date. A refund will not be issued for a required by M.S. 270C.306. If all the infor-
• Minnesota State Auditor 2009 Form PCR filed after that date. mation, other than your phone number and
banking information, is not provided, your
Completing Form PCR
You may also receive a refund of all or a
application may be delayed or denied.
portion of contributions you made in 2009 Important: You must enter your name,
to the: address, date of birth and Social Security Your Social Security number and all other
number (and your spouse’s name, date of
• Independence Party information on Form PCR are private and
birth and Social Security number if filing a
• Republican Party cannot be disclosed to others without your
joint application) in the heading of Form
• Democratic Farmer-Labor (DFL) Party consent. However, your contribution can be
PCR. Also, be sure to indicate the number
• Green Party tabulated with those of other contributors
of receipts you are attaching. If this infor-
• any precinct, city, county, congressional to that candidate or political party, and the
mation is not included, your refund may be
or legislative district unit of the Minne- total can be given to the Campaign Finance
delayed.
sota parties listed above. and Public Disclosure Board.
Filing status boxes
Who may file If you owe delinquent Minnesota taxes,
If you are single, check the Single box.
To be eligible for the refund, you must be a criminal fines or a debt to a state or county
registered voter in Minnesota or, if you are agency, district court, qualifying hospital or
If you are married, you may:
not a registered voter, you must: public library, state law requires the Depart-
• file one application together with your ment of Revenue to apply your refund to
• be a United States citizen, spouse for a maximum refund of $100, or the amount you owe (including penalty
• be age 18 or older, and • each file a separate application for a and interest on the taxes). If you participate
• have lived in Minnesota at least 20 days maximum refund of $50 each. in the Senior Citizens Property Tax Defer-
immediately before any 2009 statewide
ral Program, your refund will be applied to
If you choose to file a joint application, you
or local election in which you would be
your deferred property tax total. Your Social
must enter the name, date of birth and So-
eligible to vote if you were registered.
Security number will be used to identify you
cial Security number for both you and your
However, regardless of whether or not you as the correct debtor.
spouse. Check the box for Married, filing
are a registered voter, you are not eligible for joint application. If you owe less than the amount of your
the refund if:
refund, you will receive the difference.
If you are married and choose to file
• you are under guardianship of the person,
separate applications, do not include your
Questions?
but have not retained the right to vote, or
spouse’s name, date of birth and Social
• you have been found by a court to be If you have questions, call 651-296-3781
Security number. Enter your name only and
legally incompetent to vote, or or 1-800-652-9094. TTY users, call 711 for
check the box for Married, filing separate
• you have been convicted of a felony and Minnesota Relay.
application.
your civil rights have not been restored.
Information will be provided in an alterna-
tive format, such as large print, upon request.