Form 5433 - Assignment Of Rights From The Seller To Purchaser For Refund

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Missouri Department of Revenue

Department Use Only

Form

(MM/DD/YY)

Assignment of Rights From the Seller to Purchaser

5433

For Refund Under Section 144.190.4(1)

Reporting Period

(MM/YY)

Missouri Tax I.D.

Federal Employer

Number

I.D. Number

Case Number

(if applicable)

The original, notarized statement must be provided to the Department. Copies, faxes, or e-mailed copies will not be accepted.

Name

Address

City

State

Zip Code

Contact Telephone Number

E-mail Address

( ___ ___ ___ ) - ___ ___ ___ - ___ ___ ___ ___

Name

Missouri Tax Identification Number

___ ___ ___ ___ ___ ___ ___ ___

Address

City

State

Zip Code

Contact Telephone Number

E-mail Address

( ___ ___ ___ ) - ___ ___ ___ - ___ ___ ___ ___

On page 2, enter each transaction for which you are requesting a refund. Enter the total number of transactions and the total

refund requested below.

Total Number of Transactions

Total Refund Requested

Under penalties of perjury, I declare that the above information and any attached supplement is true, complete, and correct. I assign to Purchaser the limited right

to seek a refund from the Missouri Department of Revenue for the listed transactions. I affirm that I have not received a refund or credit of sales or use tax

paid on the transactions and I will not apply for a refund or credit of the tax collected on any transaction covered by this agreement. I authorize the Missouri

Department of Revenue to amend my sales or use tax returns as a result of any refund granted. I am authorized to execute this assignment on behalf of the seller.

Signature

Title

Printed Name

Date (MM/DD/YYYY)

__ __ /__ __ /__ __ __ __

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 (MM/DD/YYYY)