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                                                                                                                                                                       Department Use Only
                                                                               Form                        Missouri Department of Revenue                              (MM/DD/YY)
                                                                                                           Request for Sales or Use Tax Cash Bond Refund
                                             472

Missouri Tax I.D. 
Number
                                                                                           Business Name                                                                                       Amount of Bond Filed (Dollars)
                                                                                                                                                                                               $                          
                                                                                           Business Address

                                Current Bond                                   Information City                                                                                                State        Zip Code

                                                                                                      Cash Bond has been filed for the required period (two consecutive years) with a satisfactory tax compliance
                                                                                                      Sold or quit business on (MM/DD/YYYY)  ___ ___ /___ ___ /___ ___ ___ ___
                                                                                                      Business never opened
                                                                                                      Other (Explain)
                Reason for Bond                                  Return Request

                                                                                           Name (Check will be issued in the name of the owner(s) listed on the Department’s records) Telephone Number (Daytime) 
                                                                                                                                                                                      (___ ___ ___) ___ ___ ___-___ ___ ___ ___
                                                                                           Address

                                             Mail Refund To                                City                                                                                                State        Zip Code

                                                                                           Under penalties of perjury, I declare that the above information and any attached supplement is true, complete, and correct.  
                                                                                           I also swear and affirm all returns have been filed and paid and there are no outstanding liabilities.
                                                                                           Signature of Taxpayer                                               Title

                                             Signature                                     E-mail Address                                                                                  Date (MM/DD/YYYY)
                                                                                                                                                                                           ___ ___ /___ ___ /___ ___ ___ ___

                                                                                                     1.                                                                                    $

                                                                                                     2.                                                                                    $
                                                                                            Cash Bond
                                                                                                     3.                                                                                    $

                                                                                                                                                               Total Amount Refunded       $ 0.00
                                             Department Use Only                           Check Amount                                          Check Date (MM/DD/YYYY)                   Refund Check Number
                                                                                                                                                 ___ ___ /___ ___ /___ ___ ___ ___
                                                                                                                                                                                                            Form 472 (Revised 12-2014)
Mail to:  Taxation Division                                                                                                        Phone: (573) 751-5860                    
                                                                                                                                                                       Visit http://dor.mo.gov/business/register/ 
                                                                                                     P.O. Box 357                  TTY:  (800) 735-2966
                                                                                                                                                                              for additional information.
                                                                                                     Jefferson City, MO 65105-0357 Fax:  (573) 522-1722
                                                                                                                                   E-mail:  businesstaxregister@dor.mo.gov  

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