0 0 0 1 1 1 1 0 
0 0 0 0 0 0 0 0 0 0 0 1 1 1 1 1 1 1 1 1 1 2 2 2 2 2 2 2 2 2 2 3 3 3 3 3 3 3 3 3 3 4 4 4 4 4 4 4 4 4 4 5 5 5 5 5 5 5 5 5 5 6 6 6 6 6 6 6 6 6 6 7 7 7 7 7 7 7 7 7 7 8 8 8 8 8 80 0 0 0 0 0 0 0 1 1 1 1 1 1 1 1 1 1 2 2 2 2 2 2 2 2 2 2 3 3 3 3 3 3 3 3 3 3 4 4 4 4 4 4 4 4 4 4 5 5 5 5 5 5 5 5 5 5 6 6 6 6 6 6 6 6 6 6 7 7 7 7 7 7 7 7 7 7 8 8 8 8 8 80 0 0 0 0 0 0 0 1 1 1 1 1 1 1 1 1 1 2 2 2 2 2 2 2 2 2 2 3 3 3 3 3 3 3 3 3 3 4 4 4 4 4 4 4 4 4 4 5 5 5 5 5 5 5 5 5 5 6 6 6 6 6 6 6 6 6 6 7 7 7 7 7 7 7 7 7 7 8 8 8 8 8 80 0 0 0 0 0 0 0 1 1 1 1 1 1 1 1 1 1 2 2 2 2 2 2 2 2 2 2 3 3 3 3 3 3 3 3 3 3 4 4 4 4 4 4 4 4 4 4 5 5 5 5 5 5 5 5 5 5 6 6 6 6 6 6 6 6 6 6 7 7 7 7 7 7 7 7 7 7 8 8 8 8 8 80 
1 1 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 52 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 52 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 52 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 51 
      0 0 0  4 4 4 4 0                                                                                                                                                 Department Use Only
      0 0 0  5 5 5 5 0                                                                Form                                                                             (MM/DD/YY)
      0 0 0  6 6 6 6 0                                            4172                         Assignment of Certificate of Deposit
      0 0 0  7 7 7 7 0 
      0 0 0  8 8 8 8 0 
      0 0 0  9 9 9 9 0 
      1 1 1  0  0  0  0  1 Missouri Tax I.D.                                                                                                            Federal Employer
                           Number 
      1 1 1  1 1 1 1 1     (Optional)                                                                                                                   I.D. Number
      1 1 1  2 2 2 2 1 
      1 1 1  3 3 3 3 1                                                                r Sales and Use Tax                                         r Cigarette Tax                           r Motor Fuel Tax 
                              Tax                                 Type
      1 1 1  4 4 4 4 1                                                                r Other Tobacco Products                                    r Transient Employer Withholding and Unemployment Tax                                 
      1 1 1  5 5 5 5 1 
      1 1 1  6 6 6 6 1 
      1 1 1  7 7 7 7 1     Owner’s Name, all Partners, Corporation, or LLC Name                                                                                             E-mail Address
      1 1 1  8 8 8 8 1 
      1 1 1  9 9 9 9 1     Business Address                                                                                                                 City                                         State          ZIP Code
      2 2 2  0 0 0 0 2 
      2 2 2  1 1 1 1 2     Taxpayer or Business Owner’s Address                                                                                             City                                         State          ZIP Code
      2 2 2  2 2 2 2 2 
      2 2 2  3 3 3 3 2 
      2 2 2  4 4 4 4 2     I,_______________________________________________________________________, being of lawful age, assign and transfer the
      2 2 2  5 5 5 5 2     Certificate of Deposit (CD) for ___________________________________________________________________________________
      2 2 2  6 6 6 6 2 
      2 2 2  7 7 7 7 2     ($ ____________________), Certificate of Deposit Number ____________________, issued ________________________, 20____, 
      2 2 2  8 8 8 8 2     by________________________________, located at ______________________________________________________________
      2 2 2  9 9 9 9 2     __________________________________, as security to the Missouri Department of Revenue (Department) in lieu of a cash bond.  
      3 3 3  0 0 0 0 3     This CD shall secure the payment of the above indicated tax and related fees, interest, additions to tax, and penalties due the state of 
      3 3 3  1 1 1 1 3     Missouri on or after the date this CD is issued.
      3 3 3  2 2 2 2 3     I understand that at any time a delinquency occurs, the Department may redeem the CD assigned by this instrument and apply 
      3 3 3  3 3 3 3 3     the proceeds to such delinquency. I agree that Administrative Rules and Revised Statutes of Missouri will govern my rights and 
      3 3 3  4 4 4 4 3     responsibilities under this assignment. If I have not maintained a satisfactory tax compliance, and my CD is automatically renewable, 
      3 3 3  5 5 5 5 3     the Department will allow the CD to renew. I understand that I will be notified when the Department elects to renew my CD.
      3 3 3  6 6 6 6 3     Service of process shall be deemed sufficient and made in the state of Missouri if mailed by U.S. mail to the Financial Institution’s address 
      3 3 3  7 7 7 7 3     as set forth above. This agreement and any legal action pertaining thereto shall be governed by and construed in accordance with these 
      3 3 3  8 8 8 8 3     terms and the laws of the state of Missouri. The parties understand and agree that the exclusive jurisdiction for any action concerning 
      3 3 3  9 9 9 9 3     this CD shall be the state of Missouri and the only venue shall be in the Circuit Court of Cole County, Missouri. The undersigned bank  
      4 4 4  0 0 0 0 4     understands and agrees that it shall be liable for prejudgment interest and attorney fees if it breaches its obligations under this CD.
      4 4 4  1 1 1 1 4     I have read the foregoing and fully understand it and certify that I am the taxpayer subject to this assignment or I have the authority to 
      4 4 4  2 2 2 2 4     execute this assignment on behalf of the Taxpayer.
      4 4 4  3 3 3 3 4 
      4 4 4  4 4 4 4 4 
      4 4 4  5 5 5 5 4                                                                Business Name
      4 4 4  6 6 6 6 4 
      4 4 4  7 7 7 7 4                                                                Owner, Officer, Partner, or Member Signature                      Title
      4 4 4  8 8 8 8 4                                  Taxpayer      of Record
      4 4 4  9 9 9 9 4 
      4 4 4  0 0 0 0 4 
      5 5 5  1 1 1 1 5                                                                 Select One:
      5 5 5  2 2 2 2 5 
                                                                                       r The   paper Certificate of Deposit is attached.
      5 5 5  3 3 3 3 5 
      5 5 5  4 4 4 4 5                                                                 r  The Certificate of Deposit is paperless.  A withdrawal slip, confirmation of withdrawal, or endorsement on the Certificate of Deposit is not 
                                                                                           required.  In the event that taxpayer becomes delinquent, and the Department seeks the redemption of the Certificate of Deposit, a written 
      5 5 5  5 5 5 5 5                                                                     request from the Department together with this Assignment is the only documentation necessary to release funds to the Department.
      5 5 5  6 6 6 6 5 
                                                                                      Bank                              Phone Number                                   By (Signature of Banking Official) 
      5 5 5  7 7 7 7 5 
                                                                      Acknowledgement                                   (___ ___ ___)___ ___ ___-___ ___ ___ ___
                                  Financial Institution 
      5 5 5  8 8 8 8 5                                                                Bank Official’s Name                                                             Title            
      5 5 5  9 9 9 9 5 
      5 5 5  0 0 0 0 5 
      6 6 6  1 1 1 1 6 
      6 6 6  2 2 2 2 6                                                                                                         *14609010001*
      6 6 6  3 3 3 3 6                                                                                                                            14609010001
      6 6 6  4 4 4 4 6 
      6 6 6  5 5 5 5 6 
      6 6 666 6 6 6 

                                                                                                 Embosser or black ink rubber stamp seal Subscribed and sworn before me, this
                                                                                                                                                                  day of                                year
                                                                                                                                         State                     County (or City of St. Louis)     My Commission Expires

                                                                                                                                         Notary Public Signature                      
                                  Notary Public
                                                                                                                                         Notary Public Name (Typed or Printed)

                                                                                                Authority to release the Certificate of Deposit is hereby granted this _____________________________________________ 

                                                                                                day of _______________________________________ 20 ______.  Please mail any proceeds from the Certificate of Deposit 

                                                                                                to _________________________________________________________________________________________________.
                                               Release
                                                                                                                                                                   Missouri Department of Revenue

                                                                                                                                                                   By: _________________________________________
                                                                                                                                                                   Title: ________________________________________

                                                                                                The Department will accept a Certificate of Deposit (CD) issued by a state or federally chartered financial institution in lieu of 
                                                                                                a Cash Bond subject to the provisions of Revised Statutes of the State of Missouri.
                 Certificate                                                       of Deposit
                                                                                                •  Form 4172 must be fully completed by the financial institution.
                                                                                                •  It must be issued jointly in the name of the owner and the Missouri Department of Revenue.
                                                                                                •  The bank official’s signature must be notarized.
                                                                                                •  Form 4172 must be signed by the sole owner, partner, corporate officer, or member.
                                                                                   Requirements •  Attach a completed signature card, if required by financial institution.
                 Assignment of CD                                                               •  Send all completed required documents to the address on Form 4172. 

                                                                                                  •  A paper CD must be:
                                                                                                 •  Issued jointly in the name of the owner and the Missouri Department of Revenue;
                                                                                                 •  A 12-month (2 year) CD; and
                                                                                                 •  Endorsed in ink by the owner.
                                                                                                •   If the CD is a “Book Entry” CD, a signed withdrawal slip or a letter from the issuing financial institution indicating how the 
                                                                                                 Department of Revenue may draw upon the CD must accompany this form.  The sole owner, a partner, a corporate officer, 
                                                                                                 or a member of a limited liability company must sign the withdrawal slip.
                                                                                                •  If the CD is paperless, check the appropriate box.
                                                                                                •  The interest derived from the CD must be compounded. If a delinquency occurs, the Department may redeem the CD.  
                                                                                                   Any proceeds from the CD exceeding the delinquency, including interest proceeds, will be converted to a cash bond.
                                               Certificate of Deposit Requirements              •  The Financial Institution must honor upon receipt all demands for payment and make payment to the Department within              
                                                                                                   thirty (30) days of receipt of the demand.

                                                                                                                                                                                                         Form 4172 (Revised 04-2018)
Mail to:
Sales and Use or Transient
Employer Withholding Tax                                                                                                      Motor Fuel Tax                       Cigarette Tax                 Other Tobacco Products
Taxation Division                                                                                                             Taxation Division                    Taxation Division             Taxation Division 
PO Box 357                                                                                                                    PO Box 300                           PO Box 811                    PO Box 3320
Jefferson City, MO  65105-0357                                                                                                Jefferson City, MO  65105-0300       Jefferson City MO 65105-0811  Jefferson City MO 65105-3320
Phone: (573) 751-5860                                                                                                         Phone: (573) 751-2611                Phone: (573) 751-7163         Phone: (573) 751-5772
Fax:  (573) 522-1722                                                                                                          Fax:  (573) 522-1720                 Fax:  (573) 522-1720          Fax:  (573) 522-1720
E-mail: businesstaxregister@dor.mo.gov                                                                                        E-mail: excise@dor.mo.gov            E-mail: excise@dor.mo.gov     E-mail: excise@dor.mo.gov 
                                                                                                                        Visit http://dor.mo.gov/business/register for additional information.
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