Fillable Form 4172 - Assignment Of Certificate Of Deposit printable pdf download

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Missouri Department of Revenue

4172

Assignment of Certificate of Deposit

Please print on white paper only

Sales and Use Tax

Cigarette Tax

Motor Fuel Tax

Other Tobacco Products

Transient Employer Withholding and Unemployment Tax

Enter Owner's Name in front of "and Missouri Department of Revenue"

Owner’s Name, all Partners, Corporation, or LLC Name

E-mail Address

and Missouri Department of Revenue

Business Address

City

State

Zip Code

Taxpayer or Business Owner’s Address

City

State

Zip Code

I,_______________________________________________________________________, being of lawful age, assign and transfer the

Certificate of Deposit (CD) for ___________________________________________________________________________________

($ ____________________), Certificate of Deposit Number ____________________, issued ________________________, 20____,

by________________________________, located at ______________________________________________________________

__________________________________, as security to the Missouri Department of Revenue (Department) in lieu of a cash bond.

This CD shall secure the payment of the above indicated tax and related fees, interest, additions to tax, and penalties due the state of

Missouri on or after the date this CD is issued.

I understand that at any time a delinquency occurs, the Department may redeem the CD assigned by this instrument and apply

the proceeds to such delinquency. I agree that Administrative Rules and Revised Statutes of Missouri will govern my rights and

responsibilities under this assignment. If I have not maintained a satisfactory tax compliance, and my CD is automatically renewable,

the Department will allow the CD to renew. I understand that I will be notified when the Department elects to renew my CD.

Service of process shall be deemed sufficient and made in the state of Missouri if mailed by U.S. mail to the Financial Institution’s address

as set forth above. This agreement and any legal action pertaining thereto shall be governed by and construed in accordance with these

terms and the laws of the state of Missouri. The parties understand and agree that the exclusive jurisdiction for any action concerning

this CD shall be the state of Missouri and the only venue shall be in the Circuit Court of Cole County, Missouri. The undersigned bank

understands and agrees that it shall be liable for prejudgment interest and attorney fees if it breaches its obligations under this CD.

I have read the foregoing and fully understand it and certify that I am the taxpayer subject to this assignment or I have the authority to

execute this assignment on behalf of the Taxpayer.

No digital signatures allowed

Business Name

Owner, Officer, Partner, or Member Signature

Title

Select One:

The paper Certificate of Deposit is attached.

The Certificate of Deposit is paperless. A withdrawal slip, confirmation of withdrawal, or endorsement on the Certificate of Deposit is not

required. In the event that taxpayer becomes delinquent, and the Department seeks the redemption of the Certificate of Deposit, a written

request from the Department together with this Assignment is the only documentation necessary to release funds to the Department.

Bank

Phone Number

By (Signature of Banking Official)

(___ ___ ___)___ ___ ___-___ ___ ___ ___

Bank Official’s Name

Title

Subscribed and sworn before me, this

Embosser or black ink rubber stamp seal

day of

year

State

County (or City of St. Louis)

My Commission Expires

Notary Public Signature

Notary Public Name (Typed or Printed)

Form 4172 (Revised 07-2013)

Form 4172 - Assignment Of Certificate Of Deposit

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