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Department Use Only
Form (MM/DD/YY)
Assignment of Rights From the Seller to Purchaser
5433 For Refund Under Section 144.190.4(1)
Reporting Period
(MM/YY)
Purchaser Purchaser
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
Contact Telephone Number E-mail Address
( ___ ___ ___ ) - ___ ___ ___ - ___ ___ ___ ___
Seller Information
r By checking this box, I , authorize the purchaser, or purchaser’s representative, to receive
information about the seller’s account regarding the periods for which a refund claim is being submitted. I understand this allows the department to
provide specific information to the purchaser regarding why the refund claim was denied or reduced for the periods requested. This authorization is
specific to this refund claim only.
On page 2, enter each transaction you are requesting a refund for. The seller should add the jurisdiction code for the location where the
sales were reported on their return.
Total Number of Transactions Total Refund Requested
$
Total Transactions
Under penalties of perjury I, declare that the above information and any attached supplement is true, complete, and correct. I assign to Purchaser the limited right
to seek a refund from the Missouri Department of Revenue for the listed transactions. I affirm that I have not received a refund or credit of sales or use tax
paid on the transactions and I will not apply for a refund or credit of the tax collected on any transaction covered by this agreement. I authorize the Missouri
Department of Revenue to amend my sales or use tax returns as a result of any refund granted. I am authorized to execute this assignment on behalf of the seller.
Signature Title
Seller’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)
*14025010001* Form 5433 (Revised 07-2023)
14025010001