Fillable Form 163 - Sales Tax Protest Payment Affidavit printable pdf download

Form 163 - Sales Tax Protest Payment Affidavit

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DOR USE ONLY

MISSOURI DEPARTMENT OF REVENUE

FORM

TAXATION DIVISION

163

P.O. BOX 3350, JEFFERSON CITY, MISSOURI 65105-3350

(573) 526-9938

TDD 1-800-735-2966

(REV. 04-2009)

SALES TAX PROTEST PAYMENT AFFIDAVIT

MITS NUMBER

REPORTING PERIOD

OWNER’S NAME

BUSINESS NAME

MAILING ADDRESS

PHONE NUMBER

(

)

CITY

STATE

ZIP CODE

PPRE

(DO NOT WRITE IN SHADED AREAS)

FPRE

This form is to be used for filing a sales tax protest payment in compliance with Section 144.700, RSMo. Use this form in conjunction with the Nonprotested Sales Tax Payment Report (DOR-2039)

when filing a partial protest payment and use by itself when filing a fully protested payment. Return completed form to: Taxation Division, P.O. Box 3350, Jefferson City, MO 65105-3350.

ADJUSTMENTS

TAX

BUSINESS LOCATION

TAX TYPE

GROSS RECEIPTS

TAXABLE SALES

AMOUNT OF TAX

RATE (%)

(INDICATE + OR – )

CITY:

STATE

CONSERVATION

1/8%

EDUCATION

LOCATION CODE:

PARKS/SOIL

1/10%

City: __ __ __ __ __

County: __ __ __

Site: __ __ __ __

ENTER TOTAL AMOUNT OF TAX FROM SCHEDULE A (Page 3)

ENTER TOTAL AMOUNT OF TAX

FINAL RETURN: If this is your final return, enter the close date below and check the reason for closing

SUBTRACT: 2% of Line 1

ONLY if paid by due date

–

your account. The Sales Tax law requires any person selling or discontinuing business to make a final

sales tax return within fifteen (15) days of the sale or closing.

TOTAL AMOUNT OF TAX DUE:

(Line 1 minus Line 2)

Date Business Closed:

ADD: Interest for late payment

Out of Business

Sold Business

Leased Business

(See Instructions)

ADD: Additions to Tax (5% per month

late of Line 3, maximum 25%)

SIGN AND DATE RETURN:

REMIT SINGLE CHECK FOR THIS

This must be signed and dated by the taxpayer or by the taxpayer’s authorized agent.

AMOUNT: (Add Lines 3, 4, 5)

Mail to: Missouri Department of Revenue, P.O. Box 3350, Jefferson City, MO 65105-3350.

If you pay by check, you authorize the Department of Revenue to process the check electronically. Any check returned unpaid may be presented again electronically.

I have direct control, supervision, or responsibility for filing this return and payment of the tax due. Under the penalties of perjury, I declare that this is a true,

accurate, and complete return. RETURN MUST BE SIGNED AND DATED.

SIGNATURE OF TAXPAYER OR AGENT

TITLE

DATE

This publication is available upon request in alternative accessible format(s).

MO 860-1157 (04-2009)