Department Use Only
                              Form                                                                  (MM/DD/YY)
                             5522         No Tax Due Request
                                                                                                              Reset Form           Print Form

Missouri Tax I.D.                                                                  Federal Employer
Number                                                                             I.D. Number

Social Security 
Number
Name of                                                                            Doing Business 
Business                                                                           As Name (DBA)

Business Mailing                                                                   City                                 State  Zip
Address

Contact                                                                            Telephone 
Person                                                                             Number

                                                     I am required to provide a No Tax Due Certificate for the following:
                             Please indicate for which city or county you are requesting the No Tax Due. You must have a registered sales location in that city 
                             or county.

                             City                                                  OR           County
                             Reason for request (Select the appropriate box below):
                               Business License      Egg License                   Liquor License         Fireworks License    Frozen Dessert   

 Reason For No Tax Due         Kennel License        Lodging License               Pharmacy               Picnic License
                             If you need a No Tax Due Certificate for any other reason, you can contact the Tax Clearance Unit at (573) 751-9268. If you need 
                             a FULL Tax Clearance, please fill out a Request for Tax Clearance (Form 943).

                             Person authorized to 
                             receive this information

                             Title                                                 Telephone 
                                                                                   Number

                             E-mail                                                Fax 
                             Address                                               Number

                             Address                                               City                                 State  ZIP

                             Signature of 
 Authorization and Signature Owner or Officer                                                     Title

                             Printed Name of                                       Telephone 
                             Owner or Officer                                      Number

                             E-mail                                                Fax 
                             Address                                               Number

                                                                                                                               Form 5522 (Revised 09-2014)
Mail, Fax,                                Taxation Division             Phone: (573) 751-9268
or E-mail to:  P.O. Box 3666                                            TDD: (800) 735-2966               *14028010001*
                                          Jefferson City, MO 65105-3666 Fax: (573) 522-1265                             14028010001
                                                                        E-mail:  taxclearance@dor.mo.gov
                                          Visit dor.mo.gov/faq/taxation/business/tax-clearance.html for additional information.