Form 5108 - Application For Tire Or Lead-Acid Battery Refund Or Credit

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CLAIM NUMBER

MISSOURI DEPARTMENT OF REVENUE

TAXATION DIVISION

FORM

P.O. BOX 3380 (573) 526‑1760

5108

JEFFERSON CITY, MISSOURI 65105‑3380

CERTIFIED NUMBER

tirebatteryfee@dor.mo.gov

(REV. 03‑2013)

APPLICATION FOR TIRE OR LEAD-ACID BATTERY

REFUND OR CREDIT

BEFORE THE DEPARTMENT CAN PROCESS YOUR CLAIM YOU MUST PROVIDE:

Include amended returns for each period in which the tax was originally reported.

Provide an exemption certificate or exemption letter for each exempt sale.

Submit invoices supporting the refund or credit claim.

PLEASE CHECK THE ACTION TO BE TAKEN:

CREDIT

REFUND

TAXPAYER OR BUSINESS NAME

NAME ON REFUND CHECK, IF DIFFERENT

MISSOURI TAX I.D. NUMBER

PHONE NUMBER

THAN TAXPAYER OR BUSINESS

( _ _ _ ) _ _ _ ‑_ _ _ _

__ __ __ __ __ __ __ __

MAILING ADDRESS

CITY, STATE, 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 power of

attorney or agent?

YES

NO (Include a copy of the Power of Attorney Form with the refund application.)

AMOUNT OVERPAID

FILE PERIODS

REASON FOR OVERPAYMENT

I declare this claim and any attached information supporting the claim is true, complete and correct.

SIGNATURE OF TAXPAYER OR AGENT

DATE (MM/DD/YYYY)

PRINT NAME AND INDICATE IF TAXPAYER OR AGENT

__ __ / __ __ / __ __ __ __

ANALYSIS OF APPROVAL OR DENIAL