301618
                                KANSAS DEPARTMENT OF REVENUE 
                                                                                                                    FOR OFFICE USE ONLY
                                     CUSTOMER RELATIONS
                                                    PO BOX 3506                                               Inactive: _______________________________
                                                                                                                            Date/Initial
                                TOPEKA, KANSAS 66625-3506
                                                                                                              Audited: _______________________________
                    PHONE: 785-368-8222                       FAX: 785-296-2073                                             Date/Initial
                                                                                                              Deleted: _______________________________
                   NOTICE OF TAX ACCOUNT CLOSURE                                                                            Date/Initial

1.__________________________    2.___________________________             3. ______________________________         4. _______________________________
       Kansas Tax Account No.              Federal Employer’s ID No.                Business Telephone Number               Officer’s Telephone Number
5._______________________________________________          6. _________________________________________________________________________________
        Business Name                                                Business Mailing Address
                                                           ________________________________________________________________________________________________
                                                                     City                                     State                     Zip Code
7._______________________________________________     8.   __________________________________________________________________________________
        Owner’s/Officer’s Name                                       Current Address
                                                           ________________________________________________________________________________________________
                                                                     City                                     State                     Zip Code

9. Effective_________________________,     ________ I wish to cancel my registration for the following tax(es). Check each box that applies and 
  enter the specific account number for that tax type.
       Retailers’ Sales ______________________________________               Bingo Enforcement _________________________________________
       Retailers’ Compensating _____________________________                 Dry Cleaning Surcharge ____________________________________
       Liquor Enforcement __________________________________                 Withholding ________________________________________________
       Liquor Drink__________________________________________                Transient Guest Tax ________________________________________
       Consumer’s Use _____________________________________                  Vehicle Rental Tax__________________________________________
       Tire Excise___________________________________________                Water Protection Fee           _______________________________________
10. Does this business currently have employees?            Yes      No If no, enter effective date: _______________________________________
11. Has there been a transfer or a change in ownership?               No  Yes If yes, complete lines a, b and c:
       a. Trade name of new business ________________________________________________________________________________________________
       b. New owner’s name __________________________________________________________________________________________________________
       c. Starting date of new business _________________________________________              Taxpayer ID No.____________________________________
12. This business has          a cash bond          an escrow bond                  a surety bond            no bond      unknown
13. Have all applicable forms for the taxes marked above been filed to date of closing?              Yes      No If no, file them with this form.
14. If this is a consolidated registration, are all locations being closed?   Yes              No If no, list the specific locations to be closed
  under “Remarks” on line 15.
15. Remarks and final settlement or arrangement for settlement: _____________________________________________________________________
  ___________________________________________________________________________________________________________________________________
  ___________________________________________________________________________________________________________________________________
SIGN
HERE    ______________________________________             __________________________________       _________________________           _____________
                   (Signature of Retailer/Employer)           (Printed Name of Retailer/Employer)                   (Title)             (Date)
        ______________________________________             __________________________________
                   (Signature of Preparer)                           (Printed Name of Preparer)

                                                              FOR OFFICE USE ONLY
Was the date that the business was discontinued estimated?              No          Yes      If yes, give source of information: _________________
______________________________________________________________________________________________________________________________________
Accounts receivable remain to be collected:          No       Yes If yes, tax type: ______________________________________________________
Mailing address: ______________________________________________________________________________________________________________________
A Jeopardy Assessment is recommended.                No    Yes If yes, tax type:________________________________________________________
A warrant is recommended. No               Yes    If yes, tax type: _______________________________________________________________________
Comments: ___________________________________________________________________________________________________________________________
Prepared by: __________________________________________________________________________                       Date: ___________________________________
CR-108 (Rev. 8-1 )9