Form 5440 - Statement Confirming Purchaser'S Efforts To Obtain An Assignment Of Rights From The Seller For Refund Under Section 144.190.4(2)

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MISSOURI DEPARTMENT OF REVENUE
TAXATION DIVISION
P.O. BOX 3350
FORM
JEFFERSON CITY, MISSOURI 65105-3350
5440
(573) 526-9938
TDD 1-800-735-2966
STATEMENT CONFIRMING PURCHASER’S EFFORTS TO OBTAIN AN ASSIGNMENT
(REV. 02-2013)
OF RIGHTS FROM THE SELLER FOR REFUND UNDER SECTION 144.190.4(2)
MISSOURI TAX I.D. NUMBER:
NAME OF PURCHASER:
___ ___ ___ ___ ___ ___ ___ ___
:
CONTACT TELEPHONE NUMBER:
ADDRESS
( ___ ___ ___ ) - ___ ___ ___ - ___ ___ ___ ___
CITY, STATE, ZIP CODE:
MISSOURI TAX I.D. NUMBER:
NAME OF SELLER:
___ ___ ___ ___ ___ ___ ___ ___
:
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 affirm that (check only one):
I have requested in writing an assignment of rights from the Seller and the Seller failed or refused to provide an assignment
within 60 days.
I am not able to locate the Seller.
The Seller is no longer in business.
I assert my right under Section 144.190.4(2), RSMo, to pursue a refund with the Missouri Department of Revenue for the
listed transactions. I am authorized to execute this statement on behalf of the purchaser.
PURCHASER 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 STATEMENT. 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-5440 (REV. 02-2013)

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