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0 0 0 1 1 1 1 0
0 0 0 0 0 0 0 0 0 0 0 1 1 1 1 1 1 1 1 1 1 2 2 2 2 2 2 2 2 2 2 3 3 3 3 3 3 3 3 3 3 4 4 4 4 4 4 4 4 4 4 5 5 5 5 5 5 5 5 5 5 6 6 6 6 6 6 6 6 6 6 7 7 7 7 7 7 7 7 7 7 8 8 8 8 8 80 0 0 0 0 0 0 0 1 1 1 1 1 1 1 1 1 1 2 2 2 2 2 2 2 2 2 2 3 3 3 3 3 3 3 3 3 3 4 4 4 4 4 4 4 4 4 4 5 5 5 5 5 5 5 5 5 5 6 6 6 6 6 6 6 6 6 6 7 7 7 7 7 7 7 7 7 7 8 8 8 8 8 80 0 0 0 0 0 0 0 1 1 1 1 1 1 1 1 1 1 2 2 2 2 2 2 2 2 2 2 3 3 3 3 3 3 3 3 3 3 4 4 4 4 4 4 4 4 4 4 5 5 5 5 5 5 5 5 5 5 6 6 6 6 6 6 6 6 6 6 7 7 7 7 7 7 7 7 7 7 8 8 8 8 8 80 0 0 0 0 0 0 0 1 1 1 1 1 1 1 1 1 1 2 2 2 2 2 2 2 2 2 2 3 3 3 3 3 3 3 3 3 3 4 4 4 4 4 4 4 4 4 4 5 5 5 5 5 5 5 5 5 5 6 6 6 6 6 6 6 6 6 6 7 7 7 7 7 7 7 7 7 7 8 8 8 8 8 80
1 1 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 52 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 52 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 52 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 51
0 0 0 4 4 4 4 0 Department Use Only
0 0 0 5 5 5 5 0 Form (MM/DD/YY)
0 0 0 6 6 6 6 0 Sales or Use Tax Protest Affidavit
0 0 0 7 7 7 7 0 163B
Reporting Period
0 0 0 8 8 8 8 0 (MM/YY)
0 0 0 9 9 9 9 0
1 1 1 0 0 0 0 1 Missouri Tax I.D. Federal Employer
1 1 1 1 1 1 1 1 Number I.D. Number
1 1 1 2 2 2 2 1
1 1 1 3 3 3 3 1 This form is to be used for filing a sales or use tax protest in accordance with sales tax regulation
1 1 1 4 4 4 4 1 12 CSR 10‑3.552 orSection 144.700, RSMo.
1 1 1 5 5 5 5 1 Firm Name Mailing Address
1 1 1 6 6 6 6 1
1 1 1 7 7 7 7 1 City State Zip Code Total Sum
1 1 1 8 8 8 8 1 Claimant
1 1 1 9 9 9 9 1 Periods Protested
2 2 2 0 0 0 0 2
2 2 2 1 1 1 1 2 A complete breakdown of each specific tax must be made.
2 2 2 2 2 2 2 2
2 2 2 3 3 3 3 2 Tax Type Tax Rate Amount
2 2 2 4 4 4 4 2 State 3%
2 2 2 5 5 5 5 2 Conservation 1/8%
2 2 2 6 6 6 6 2 Education 1%
2 2 2 7 7 7 7 2 Parks and Soil 1/10%
2 2 2 8 8 8 8 2
2 2 2 9 9 9 9 2
3 3 3 0 0 0 0 3 Protested Amount(s)
3 3 3 1 1 1 1 3
3 3 3 2 2 2 2 3
3 3 3 3 3 3 3 3
3 3 3 4 4 4 4 3 Total
3 3 3 5 5 5 5 3
3 3 3 6 6 6 6 3
3 3 3 7 7 7 7 3
3 3 3 8 8 8 8 3
3 3 3 9 9 9 9 3
4 4 4 0 0 0 0 4
4 4 4 1 1 1 1 4 Reason for Protest
4 4 4 2 2 2 2 4
4 4 4 3 3 3 3 4 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.
4 4 4 4 4 4 4 4 Under penalties of perjury, I declare that the above information and any attached supplement is true, complete, and correct.
4 4 4 5 5 5 5 4 Signature of Taxpayer or Agent Title Date (MM/DD/YYYY)
4 4 4 6 6 6 6 4 Signature __ __ /__ __ /__ __ __ __
4 4 4 7 7 7 7 4
4 4 4 8 8 8 8 4 Embosser or black ink rubber stamp seal Subscribed and sworn before me, this
4 4 4 9 9 9 9 4 day of year
4 4 4 0 0 0 0 4 State County (or City of St. Louis) My Commission Expires (MM/DD/YYYY)
5 5 5 1 1 1 1 5
__ __ /__ __ /__ __ __ __
5 5 5 2 2 2 2 5
5 5 5 3 3 3 3 5 Notary Public Signature
5 5 5 4 4 4 4 5
5 5 5 5 5 5 5 5 Notary Information Notary Public Name (Typed or Printed)
5 5 5 6 6 6 6 5
5 5 5 7 7 7 7 5 Form 163B (Revised 02-2020)
5 5 5 8 8 8 8 5 Mail to: Taxation Division Phone:(573) 526-9938
P.O. Box 3350 TTY: (800) 735-2966 Visit http://dor.mo.gov/business/sales/
5 5 5 9 9 9 9 5 for additional information.
Jefferson City, MO 65105-3350 Fax: (573) 751-9409
5 5 5 0 0 0 0 5 E‑mail: salesrefund@dor.mo.gov
6 6 6 1 1 1 1 6
6 6 6 2 2 2 2 6 *14009010001*
6 6 6 3 3 3 3 6 14009010001
6 6 6 4 4 4 4 6
6 6 6 5 5 5 5 6
6 6 666 6 6 6
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