MISSOURI DEPARTMENT OF REVENUE
BUSINESS TAX
FORM
P O BOX 840, JEFFERSON CITY MISSOURI 65105-0840
2477
(573) 751-2836
TDD 1-800-735-2966
MISSOURI SALES TAX AFFIDAVIT
(REV. 12-99)
FOR HANDICRAFT ITEMS
STATE OF MISSOURI
SOCIAL SECURITY NUMBER
COUNTY OF
I,
(RESPONSIBLE PERSON)
whose address is
being duly sworn, depose and state:
That all sales of handicraft items are made by me, the seller, or my spouse. That my spouse or I are at least sixty-five years
of age. That the proceeds from such sales do not constitute a majority of my annual gross income.
That I will remain knowledgeable of the statutes and regulations regarding such sales and that I will immediately notify
Business Tax, Missouri Department of Revenue, of any change in circumstance which could reasonably lead me to believe
that I would no longer qualify as exempt, either because of a change in the law or because of a change in my activities.
That it is understood that any misrepresentation contained herein or failure on my part to fulfill the promises entered into
herein will result in the immediate revocation of any exemption letter issued to:
(SIGNATURE)
by Business Tax, Missouri Department of Revenue.
NOTARY PUBLIC
NOTARY PUBLIC EMBOSSER SEAL
STATE
COUNTY (OR CITY OF ST. LOUIS)
SUBSCRIBED AND SWORN BEFORE ME, THIS
USE RUBBER STAMP IN CLEAR AREA BELOW
DAY OF
20
NOTARY PUBLIC SIGNATURE
MY COMMISSION
EXPIRES
NOTARY PUBLIC NAME (TYPED OR PRINTED)
This publication is available upon request in alternative accessible format(s).
MO 860-1536 (12-99)