Form St-21 - Sales And Use Tax Refund Application - 2007 Page 3

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PART E – ASSIGNMENT OF RIGHT TO REFUND
ASSIGNMENT OF RIGHT TO REFUND
Pursuant to K.S.A. 79-3650(a)(4)
Retailer assignment of right to allow purchaser/consumer to file refund request directly with
the Kansas Department of Revenue (KDOR)
(1) My name is _______________________________ , and I am a duly authorized representative of ________________
_____________________________________ (the “Assignor/Retailer”). By executing this Assignment of Right to a
Refund (“Assignment”), the Assignor/Retailer assigns all rights and interest to the tax refund herein described that the
Assignor/Retailer may have to ____________________ (the “Assignee/Consumer”), subject to the limitation noted herein.
The Assignee’s/Consumer’s federal Employer Identification Number (EIN) is ________________________ .
(2) The tax refund that is subject of this Assignment is described as follows:
Tax Type: __________________________________
Period(s): _________________________________________
Requested Amount: _________________________
Transactions:___________________________________________________________ (Attach schedule if necessary)
Please explain other specific limitations: ______________________________________________________________
(3) The Assignor/Retailer agrees to provide to the Assignee/Consumer any information or documentation in their possession
needed for submission to KDOR to support or prove the refund request. Assignor/Retailer waives confidentiality to the
extent necessary for KDOR to verify the tax sought to be refunded was remitted to KDOR.
(4) By executing this Assignment, the Assignor/Retailer affirms that the Assignor/Retailer remitted the tax sought to be
refunded and has neither previously claimed a refund nor taken a credit on a return for taxes that are subject of this
Assignment, and further affirms that the Assignor/Retailer will not claim a refund or a credit for those taxes in the future
in accordance with K.S.A. 79-3615(j).
(5) The Assignor/Retailer understands the Assignor/Retailer shall be subject to the penalties of K.S.A. 79-3615(h) for any
false information provided in this statement. [$500 to $10,000 fine and one to six months imprisonment]
_______________________________________________________
__________________________
Assignor/Retailer Entity Name
Tax Account Number
_______________________________________________________
__________________________
Print or type the name of the person authorizing assignment
Relationship to Entity
_______________________________________________________
__________________________
Signature of person authorizing assignment
Date
I certify under penalties of perjury that, to the best of my knowledge, all of the information and statements made in this
Assignment of Right to Refund are true and correct.
STATE OF KANSAS
)
) SS:
COUNTY OF __________________________
)
This Assignment of Right to Refund was acknowledged before me on _____________________________, 20 _____ by
__________________________________________ as _________________________________________.
Name of Assignor/Retailer and Official Capacity (officer, superintendent, business manager, etc.)
Notary Public: ________________________________
My appointment expires: _______________________________
11

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