Fillable Printable Form 163B Sales Or Use Tax Protest Affidavit

Form 163B Sales Or Use Tax Protest Affidavit

Form

163B

This form is to be used for filing a sales or use tax protest in accordance with sales tax regulation

12 CSR 10‑3.552 or Section 144.700, RSMo.

Missouri Department of Revenue

Sales or Use Tax Protest Affidavit

Mail to: Taxation Division Phone: (573) 526-9938

P.O. Box 3350 TTY: (800) 735-2966

Jefferson City, MO 65105-3350 Fax: (573) 751-9409

E‑mail: [email protected]

Visit http://dor.mo.gov/business/sales/

for additional information.

Form 163B (Revised 12-2014)

Notary Information

Subscribed and sworn before me, this

day of year

State County (or City of St. Louis) My Commission Expires (MM/DD/YYYY)

Notary Public Signature

Notary Public Name (Typed or Printed)

Embosser or black ink rubber stamp seal

__ __ /__ __ /__ __ __ __

Reason for Protest

Signature of Taxpayer or Agent Title Date (MM/DD/YYYY)

Under penalties of perjury, I declare that the above information and any attached supplement is true, complete, and correct.

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.

Signature

__ __ /__ __ /__ __ __ __

*14009010001*

14009010001

Firm Name Mailing Address

City State Zip Code Total Sum

Periods Protested

Claimant

A complete breakdown of each specific tax must be made.

Tax Type

Tax Rate

Amount

State 3%

Conservation 1/8%

Education 1%

Parks and Soil 1/10%

Total

Protested Amount(s)

Department Use Only

(MM/DD/YY)

Missouri Tax I.D.

Number

Federal Employer

I.D. Number

Reporting Period

(MM/YY)

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