Form 4379a - Request For Information Of Local License Renewal Current/delinquent Records
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2MISSOURI DEPARTMENT OF REVENUE
FORM
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REQUEST FOR INFORMATION OF
4379A
LOCAL LICENSE RENEWAL
CURRENT/DELINQUENT RECORDS
(REV. 9-2007)
The political subdivision of
, Missouri, pursuant to the provisions of
Sections 32.057 and 144.121, RSMo, formally requests to inspect or audit any and all records requested below pertaining to the adminis-
tration, collection and enforcement of its sales and requires all merchants to be current in the payment of all sales/use tax to the Director of
Revenue before renewing their business license. We request that your office notify all delinquent taxpayers within our jurisdiction that they
will be required to present a statement of No Tax Due in order to review their business license and provide us with a report of all clear
accounts and a report of all delinquent accounts within our jurisdiction.
Notification and reports should be sent
Reports in:
Date
Account Order
Merchants must renew licenses by
Alphabetical Order
Date
CONTACT PERSON
TITLE
PHONE
FAX
(___ ___ ___) ___ ___ ___ - ___ ___ ___ ___
(___ ___ ___) ___ ___ ___ - ___ ___ ___ ___
As chief executive of this political subdivision, I authorize and hereby confirm that the individual(s) named below will receive and/or
perform the inspection or audit on behalf of the political subdivision. We have reviewed and will comply with Sections 144.121, 144.122,
and 32.057, RSMo pertaining to the strict confidentiality of all records of the Missouri Department of Revenue to which access has been
granted.
PRINT NAME OF CHIEF EXECUTIVE
SIGNATURE OF CHIEF EXECUTIVE
TITLE
DATE
__ __ / __ __ / __ __ __ __
AUDITOR/AUTHORIZED INDIVIDUALS
PRINT NAME OF AUDITOR/AUTHORIZED INDIVIDUAL RECEIVING REPORT
SIGNATURE OF AUDITOR/AUTHORIZED INDIVIDUAL RECEIVING REPORT
DATE
___ ___ / ___ ___ / ___ ___ ___ ___
PRINT NAME OF AUDITOR/AUTHORIZED INDIVIDUAL RECEIVING REPORT
SIGNATURE OF AUDITOR/AUTHORIZED INDIVIDUAL RECEIVING REPORT
DATE
___ ___ / ___ ___ / ___ ___ ___ ___
PRINT NAME OF AUDITOR/AUTHORIZED INDIVIDUAL RECEIVING REPORT
SIGNATURE OF AUDITOR/AUTHORIZED INDIVIDUAL RECEIVING REPORT
DATE
___ ___ / ___ ___ / ___ ___ ___ ___
INDICATE THE ADDRESS OF POLITICAL SUBDIVISION
POLITICAL SUBDIVISION
STREET
CITY
STATE
ZIP CODE
___ ___ ___ ___ ___
Mail completed form to: Missouri Department of Revenue, Customer Services Division, P.O. Box 3666, Jefferson City, MO 65105-3666 or
fax to: (573) 522-1160.
FOR DEPARTMENT USE ONLY
DATE RECEIVED
COUNTY CODE
CITY CODE(S)
This publication is available upon request in alternative accessible format(s).
MO 860-0180 (9-2007)
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