Form 472s - Seller'S Claim For Sales Or Use Tax Refund Or Credit Page 2
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Missouri Department of Revenue
472S
Seller’s Claim for Sales or Use Tax Refund or Credit
Claim Number (Department Use Only)
Certified Number (Department Use Only)
Please check the action to be taken:
r
Credit
r
Refund
Seller Name
Name on refund check, if different than seller
Missouri Tax I.D. Number
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Mailing Address
Phone Number
(
)
-
___ ___ ___
___ ___ ___
___ ___ ___ ___
City, State, and Zip Code
Do you want the Department of Revenue to send copies of any correspondence relating to this refund and the final refund approval or denial to
your attorney?
NO
YES (If yes, include a copy of the Power of Attorney (Form 2827) with the refund application.)
Requested Refund or Credit Amount
Filing Periods Covered by Refund or Credit Claim
$
Reason for requesting a refund - Explain the specific grounds upon which your claim for refund or credit is based. If your refund is for an amount
that exceeds $100,000, an Agreement To Receive Refund By ACH Transfer (Form 5378) is required.
Provide if you are making a claim on behalf of the purchaser.
Amount of Refund
Name
City - State - Zip Code
Street Address or PO Box
Requested
$
$
$
$
$
$
Under penalties of perjury, I declare that the above information and any attached supplement is true, completed, and correct.
Signature of Taxpayer or Power of Attorney
Printed Name
Date (MM/DD/YYYY)
I confirm that I am the following (check one)
r
r
Taxpayer
Power of Attorney
___ ___ / ___ ___ / ___ ___ ___ ___
Mail to:
Phone: (573) 526-9938
Missouri Department of Revenue
Visit dor.mo.gov/business/sales/
TDD: (800) 735-2966
Taxation Division
Fax: (573) 751-9409
P.O. Box 3350
for additional information.
E-mail: salesrefund@dor.mo.gov
Jefferson City, MO 65105-3350
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