Form 472b - Application For Sales/use Tax Refund/credit 2010

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CLAIM NUMBER

MISSOURI DEPARTMENT OF REVENUE

FORM

TAXATION DIVISION

P.O. BOX 3350

(573) 526-9938 TDD (800) 735-2966

472B

JEFFERSON CITY, MISSOURI 65105-3350

CERTIFIED NUMBER

(REV. 01-2010)

salesrefund@dor.mo.gov

APPLICATION FOR SALES/USE TAX REFUND/CREDIT

BEFORE THE DEPARTMENT CAN PROCESS YOUR CLAIM YOU MUST PROVIDE:

Checklist

Indicate on the application whether you are requesting a refund or a

Provide a worksheet detailing how the refund/credit amount is

credit.

calculated.

Complete the claimant portion of the application. (See back for

Submit invoices supporting the refund/credit claim. (If the refund/credit

detailed explanation.)

request is for more than one tax period, invoices for the entire claim

may not be required. Contact the Department of Revenue at (573)

Sign the refund/credit application.

526-9938 before submitting invoices for more than one period.)

Include amended returns for each period in which the tax was

Include a properly executed power of attorney if someone other than

originally reported.

an owner, partner, or officer is the contact person concerning the

Provide a copy of the exemption certificate or exemption letter for an

refund/credit claim.

exempt sale.

PLEASE CHECK THE ACTION TO BE TAKEN:

CREDIT

REFUND

TAXPAYER/BUSINESS NAME

NAME ON REFUND CHECK, IF DIFFERENT

MISSOURI TAX I.D. NUMBER

PHONE NUMBER

THAN TAXPAYER/BUSINESS

__ __ __ __ __ __ __ __ ( _ _ _ ) _ _ _ - _ _ _ _

MAILING ADDRESS

CITY, STATE, ZIP CODE

Do you want the Department of Revenue to send copies of any correspondence relating to this refund and the final refund approval/denial to your power of

attorney or agent?

YES

(Include a copy of the Power of Attorney Form with the refund application.)

AMOUNT OVERPAID

FILE PERIODS

REASON FOR OVERPAYMENT

I declare this claim and any attached information supporting the claim is true, complete and correct. I also declare under penalties of perjury that I employ

no illegal or unauthorized aliens as defined under federal law and that I am not eligible for any tax exemption, credit or abatement if I employ such aliens.

SIGNATURE OF TAXPAYER OR AGENT

DATE

PRINT NAME AND INDICATE IF TAXPAYER OR AGENT

_ _ / _ _ / _ _ _ _

DEPARTMENT USE ONLY

You have the right to appeal any amount denied. See Frequently Asked Questions

INTEREST

on the reverse side of this form for appeal procedures.

REFUND/CREDIT TOTAL

EXPLANATION

INITIATED

DATE