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Department Use Only
Form
(MM/DD/YY)
163 Sales Tax Protest Payment Affidavit
Reporting Period
(MM/YY)
Missouri Tax I.D. Federal Employer
Number I.D. Number
Case Number
(if applicable)
Owner’s Name Business Name
Mailing Address City
Business State ZIP Code Phone Number PPRE
Department Use Only FPRE
(__ __ __) __ __ __ - __ __ __ __
This form is to be used for filing a sales tax protest payment in compliance with Section 144.700, RSMo. Use this form in conjunction with the
Nonprotested Sales Tax Payment Report (Form 2039) when filing a partial protest payment and use by itself when filing a fully protested payment.
Business Location Tax Type Gross Receipts Adjustments Taxable Sales Tax Amount of Tax
Indicate + or – ) Rate (%)
City: State - 3%
Conservation - 1/8%
Location Code: Education - 1%
Parks and Soil - 1/10%
City: __ __ __ __ __ -
County: __ __ __ -
Site: __ __ __ __ -
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Enter total amount of tax from Schedule A (Page 3)
Protested Payment(s) Enter Total Amount Of Tax 1.
Final Return: If this is your final return, enter the close date below and select Subtract: 2% of Line 1 2.
the reason for closing your account. The Sales Tax law requires any person only if paid by due date
–
selling or discontinuing business to make a final sales tax return within 15 days Total amount of tax due: 3.
of the sale or closing. (Line 1 minus Line 2)
=
Date Business Closed (MM/DD/YYYY) __ __ /__ __ /__ __ __ __ Add: Interest for late payment 4.
(See Instructions)
+
r Leased Business r Out of Business r Sold Business Add: Additions to Tax (5% per month 5.
late of Line 3, maximum 25%)
+
If you pay by check, you authorize the Department of Revenue to process Remit single check for this 6.
the check electronically. Any check returned unpaid may be presented amount: (Add Lines 3, 4, 5)
again electronically. =
Department Use Only
*14008010001*
14008010001 Form 163 (Revised 02-2020)