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                                                                                                                                        Department Use Only
                                                                 Form                                                                   (MM/DD/YY)
                                                                           Sales or Use Tax Protest Affidavit
 163B
                                                                                                                                                          Reporting Period
                                                                                                                                                          (MM/YY)

Missouri Tax I.D.                                                                                                            Federal Employer
Number                                                                                                                       I.D. Number
                                                                                This form is to be used for filing a sales or use tax protest in accordance with sales tax regulation
                                                                                                          12 CSR 10‑3.552 or Section 144.700, RSMo.
                                                                 Firm Name                                                   Mailing Address

                                                                 City                                            State       Zip Code           Total Sum 
                                      Claimant
                                                                 Periods Protested

                                                                 Reset This Section Only        A complete breakdown of each specific tax must be made.
                                                                                                Tax Type                                              Tax Rate             Amount
                                                                 State                                                                                 3%
                                                                 Conservation                                                                         1/8%
                                                                 Education                                                                             1%
                                                                 Parks and Soil                                                                       1/10%

                   Protested Amount(s)

                                                                                                                                                       Total

                   Reason for Protest

                                                                 If you pay by check, you authorize the Department of Revenue to process the check electronically.  Any check returned unpaid may be presented again electronically.
                                                                 Under penalties of perjury, I declare that the above information and any attached supplement is true, complete, and correct.
                                                                 Signature of Taxpayer or Agent                                   Title                                   Date (MM/DD/YYYY)
                                      Signature                                                                                                                           __ __ /__ __ /__ __ __ __
                                                                 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 163B (Revised 02-2020)
Mail to:  Taxation Division                                                                               Phone: (573) 526-9938
                                                                       P.O. Box 3350                      TTY: (800) 735-2966           Visit http://dor.mo.gov/business/sales/
                                                                       Jefferson City, MO 65105-3350      Fax: (573) 751-9409                  for additional information.
                                                                                                          E‑mail:  salesrefund@dor.mo.gov

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