Form 4379 - Request For Information/audit Of Local Sales/use Tax Records
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FORM
MISSOURI DEPARTMENT OF REVENUE
4379
REQUEST FOR INFORMATION/AUDIT OF
LOCAL SALES/USE TAX RECORDS
(REV. 01-2010)
The political subdivision of
, Missouri, pursuant to the provisions of Sections 32.057 and 144.121,
RSMo, formally requests to inspect or audit any and all records requested below pertaining to the administration, collection and enforcement of its sales/use tax. (Please
indicate the tax periods for which you are requesting the information, the format of CD and frequency in which you wish to receive the reports.)
ENDING DATE
REPORT
BEGINNING DATE
TAX TYPE
FORMAT OF CD
OF REPORT
OF REPORT
FREQUENCY
Monthly
Text
Sales Tax
Quarterly
Image
Option Use Tax
Semi-Annually
Annually
JULY
JUNE
Free Report*
*Each city/county may receive one free report each year. This report reflects information from the most current fiscal year. The department’s fiscal year runs from July to
June. See back of form for additional information.
CONTACT PERSON
TITLE
PHONE
FAX
(__ __ __) __ __ __ - __ __ __ __
(__ __ __) __ __ __ - __ __ __ __
EXPLAIN IN DETAIL
As chief executive of this political subdivision, I authorize and hereby confirm that the individual(s) named below will receive and/or perform the inspection or audit on
behalf of the political subdivision. We have reviewed and will comply with Sections 144.121, 144.122, and 32.057, RSMo pertaining to the strict confidentiality of all
records of the Missouri Department of Revenue to which access has been granted.
PRINT NAME OF CHIEF EXECUTIVE
SIGNATURE OF CHIEF EXECUTIVE
TITLE
DATE
_ _ / _ _ / _ _ _ _
AUTHORIZED INDIVIDUALS RECEIVING/REVIEWING REPORT(S)
PRINT NAME
SIGNATURE
DATE
_ _ / _ _ / _ _ _ _
_ _ / _ _ / _ _ _ _
_ _ / _ _ / _ _ _ _
_ _ / _ _ / _ _ _ _
INDICATE THE ADDRESS TO WHICH THE REPORTS SHOULD BE SENT.
NAME OF AUTHORIZED INDIVIDUAL RECEIVING REPORT(S)
POLITICAL SUBDIVISION
ADDRESS
CITY
STATE
ZIP CODE
_ _ _ _ _
FAX
EMAIL
(__ __ __) __ __ __ - __ __ __ __
FOR DEPARTMENT USE ONLY
DATE APPROVED
DATE COMPLETED
COUNTY CODES
CITY CODES
DISTRICT CODES
MAIL COMPLETED FORM TO: MISSOURI DEPARTMENT OF REVENUE, TAXATION DIVISION, P.O. BOX 3380, JEFFERSON CITY, MO 65105-3380 or fax to (573)522-1160.
This publication is available upon request in alternative accessible format(s).
MO 860-0180 (01-2010)
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