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Missouri Department of Revenue
Form
472
Request for Sales or Use Tax Cash Bond Refund
Business Name
Missouri Tax Identification Number
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Business Address
City
State
Zip Code
Amount of Bond Filed
Date Bond Filed (MM/DD/YYYY)
Dollars ($
)
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r
Cash Bond has been filed for the required period (two consecutive years) with a satisfactory tax compliance
r
Sold or quit business on (MM/DD/YYYY)
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r
Business never opened
r
Other (Explain)
Name (Check will be issued in the name of the owner(s) listed on the Department’s records)
Address
City
State
Zip Code
Telephone Number (Daytime)
(
)
-
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Under penalties of perjury, I declare that the above information and any attached supplement is true, complete, and correct. I
also swear and affirm all returns have been filed and paid and there are no outstanding liabilities.
Signature of Taxpayer
Title
Date (MM/DD/YYYY)
___ ___ / ___ ___ / ___ ___ ___ ___
E-mail Address
Cash Bond
1.
$
2.
$
3.
$
$
Total Amount Refunded
Refund Check Number
Check Date (MM/DD/YYYY)
Check Amount
___ ___ / ___ ___ / ___ ___ ___ ___
Form 472 (Revised 06-2013)
Mail to:
Phone: (573) 751-5860
Taxation Division
Visit
P.O. Box 357
TDD: (800) 735-2966
for additional information.
Jefferson City, MO 65105-0357
Fax: (573) 522-1722
E-mail: businesstaxregister@dor.mo.gov