Fillable Form 163 - Sales Tax Protest Payment Affidavit (Page 2 of 4) in pdf

Form 163 - Sales Tax Protest Payment Affidavit Page 2

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Page 2

Note: Sales Tax Regulation

12 CSR 10-3.552

or Section 144.700, RSMo, must be complied with or the protest payment will be deposited to General

Revenue.

Subscribed and sworn before me, this

Embosser or black ink rubber stamp seal

day of

year

State

County (or City of St. Louis)

My Commission Expires

Notary Public Signature

Notary Public Name (Typed or Printed)

Disposition

Reason

Date

__ __ /__ __ /__ __ __ __

Under penalties of perjury, I declare that the above information and any attached supplement is true, complete, and correct. I have direct control,

supervision, or responsibility for filing this return and payment of the tax due. I attest that I have no gross receipts to report for locations left blank.

Taxpayer or Authorized Agent’s Signature

Title

Date (MM/DD/YYYY)

__ __ /__ __ /__ __ __ __

Printed Name

Tax Period (MM/DD/YYYY) though (MM/DD/YYYY)

__ __ /__ __ /__ __ __ __

through

__ __ /__ __ /__ __ __ __

Form 163 (Revised 12-2014)

Mail to:

Phone: (573) 526-9938