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                                                                                                     Department Use Only
                        Form    Statement Confirming Purchaser’s Efforts to Obtain                  (MM/DD/YY)
                                an Assignment of Rights From the Seller
5440                            For Refund Under Section 144.190.4(2)                                         Reporting Period
                                                                                                              (MM/YY)

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

Case Number
Department Use Only

                        Name

                        Address                                                                     

                        City                                                                                  State           ZIP Code                                    

                        Contact Telephone Number                         E-mail Address
Purchaser Information   ( ___ ___ ___ ) - ___ ___ ___ - ___ ___ ___ ___

                        Name                                                                                  Missouri Tax Identification Number
                                                                                                              ___ ___ ___ ___ ___ ___ ___ ___
                        Address                                                                     

                        City                                                                                  State           ZIP Code                                    

Seller Information      Contact Telephone Number                         E-mail Address
                        ( ___ ___ ___ ) - ___ ___ ___ - ___ ___ ___ ___

                        In detail, please complete the information below. Attach a second page, if needed.

                                                                                        Year of 
                                Description of Taxable                    Cost of Good  Month and          Street, City, and State of Purchase Amount of Refund 
                                Good or Service                           or Service    Purchase                                                Requested

                        1.                                              $                                                                      $
                        2.                                              $                                                                      $
                        3.                                              $                                                                      $
                        4.                                              $                                                                      $
            Transactions
                        5.                                              $                                                                      $
                        6.                                              $                                                                      $
                        7.                                              $                                                                      $
                        8.                                              $                                                                      $

                                                         *14026010001*
                                                                          14026010001                                         Form 5440 (Revised 07-2023)

                       Under penalties of perjury, I declare that the above information and any attached supplement is true, complete, and correct. 
                       I affirm that (select only one):
                        r I have requested in writing an assignment of rights from the Seller and the Seller failed or refused to provide an assignment within 60 days.
                        r I am not able to locate the Seller.              r The Seller is no longer in business.
                       I assert my right under Section 144.190.4(2), RSMo, to pursue a refund with the Missouri Department of Revenue for the listed transactions. I am authorized to execute 
                       this statement on behalf of the purchaser.
                       Signature                                                                                  Title

 Purchaser’s Signature Printed Name                                                                               Date (MM/DD/YYYY)
                                                                                                                  __ __ /__ __ /__ __ __ __

                        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 (MM/DD/YYYY)
                                                                                                                         __ __ /__ __ /__ __ __ __
                                                                          Notary Public Signature                 

 Notary Information                                                       Notary Public Name (Typed or Printed) 

                                                                                                                                                    Form 5440 (Revised 07-2023)

Mail to:  Taxation Division                                              Phone: (573) 526-9938                             Visit  
                        P.O. Box 3350                                    Fax: (573) 751-9409        http://dor.mo.gov/faq/business/refund.php 
                        Jefferson City, MO 65105-3350                    TTY:  1-800-735-2966                     for additional information.
                                                                         E-mail:  salesrefund@dor.mo.gov

                                                                 *14026020001*
                                                                                   14026020001