Form 5433 - Assignment Of Rights From The Seller To Purchaser For Refund Under Section 144.190.4(1)

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MISSOURI DEPARTMENT OF REVENUE
TAXATION DIVISION
P.O. BOX 3350
FORM
JEFFERSON CITY, MISSOURI 65105-3350
5433
(573) 526-9938
TDD 1-800-735-2966
(REV. 02-2013)
ASSIGNMENT OF RIGHTS FROM THE SELLER TO PURCHASER FOR REFUND UNDER SECTION 144.190.4(1)
MISSOURI TAX I.D. NUMBER:
NAME OF SELLER:
___ ___ ___ ___ ___ ___ ___ ___
:
CONTACT TELEPHONE NUMBER:
ADDRESS
( ___ ___ ___ ) - ___ ___ ___ - ___ ___ ___ ___
CITY, STATE, ZIP CODE:
MISSOURI TAX I.D. NUMBER:
NAME OF PURCHASER:
___ ___ ___ ___ ___ ___ ___ ___
:
CONTACT TELEPHONE NUMBER:
ADDRESS
( ___ ___ ___ ) - ___ ___ ___ - ___ ___ ___ ___
CITY, STATE, ZIP CODE:
If more space is needed for the information below, please attach a second page.
TAX PERIOD
AMOUNT
DESCRIPTION OF TAXABLE
COST OF GOOD
TAX LOCATION REPORTED
REPORTED TO
OF REFUND
GOOD OR SERVICE
OR SERVICE
TO DEPARTMENT
DEPARTMENT
REQUESTED
$
$
1
.
$
$
2.
$
$
3.
$
$
4.
$
$
5.
$
$
6.
$
$
7.
$
$
8.
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.
SELLER PRINTED NAME
TITLE
___ ___ /___ ___ /___ ___ ___ ___
SIGNATURE
DATE (MM/DD/YYYY)
THIS FORM IS COMPLETED UNDER PENALTY OF PERJURY. ANY PERSON SIGNING THIS FORM DECLARES THAT IT IS TRUE, COMPLETE, AND
ACCURATE TO THE BEST OF HIS OR HER KNOWLEDGE AND BELIEF. YOU MUST PROVIDE THE ORIGINAL ASSIGNMENT OF RIGHTS. THE
DEPARTMENT CANNOT ACCEPT A COPY, FAX, OR E-MAILED COPY BECAUSE THE STATUTE REQUIRES THE FORM BE NOTARIZED.
NOTARY PUBLIC EMBOSSER OR BLACK
STATE:
COUNTY:
RUBBER STAMP SEAL
SUBSCRIBED AND SWORN BEFORE ME THIS :
DAY OF
NOTARY PUBLIC SIGNATURE:
MY COMMISSION EXPIRES:
NOTARY PUBLIC NAME (TYPED OR PRINTED):
DOR-5433 (REV. 02-2013)

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