Tax Audit & Collections 
                                                                                     20 East Main Street, Suite 450 
                                                                                         PO Box 1466 
                                                                                     Mesa, Arizona  85211-1466 
                                                                                     (480) 644-2051 Tel 
                                                                                     (480) 644-2687 Fax 
                                                                                                            
                                         Tax Clearance Request Form 
                                                  
  Date:          
   
  Transaction Privilege Tax#                     
   
  Requestor’s Name:                                                                  
   
  Name of Business:                                                                                                                                                         
   
  Address:                                         
   
  City:                 State:         Zip code:       Phone #:             Fax #:            
   
  Mailing address to mail request:              
   
  The Reason for the request of the Tax Clearance:                                                         
   
     Dissolution of Corporation          Date of Dissolution of Corporation:             
   
     Sale of Business   Date of the Sale:           Transaction Privilege Tax#           
   
   Name of New Owner:                            
   
   Address:                                        
   
   City:                     State:         Zip code:       
    
   Phone:                  
   
     Other (please specify):             
   
  Signature:  _____________________________________
   
  Print Name: _____________________________________ 
   
  Title:      _____________________________________ 
              (Corporate Officer, Partner, Owner) 
   
  Print and Mail form to: City of Mesa, Tax Audit & Collections, PO Box 1466, Mesa, AZ, 8211-1466.