Tax Clearance Request Form - City Of Mesa

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Tax Audit & Collections
20 East Main Street, Suite 450
PO Box 1466
Mesa, Arizona 85211-1466
(480) 644-2051 Tel
(480) 644-2687 Fax
Tax Clearance Request Form
Date:
_______________
Transaction Privilege Tax#
______________________________
Requestor’s Name:
__________________________________________
Name of Business:
__________________________________________
Address: _____________________________________________________
City: ______________ State: ________ Zip code: __________
The Reason for the request of the Tax Clearance:
Dissolution of Corporation
Date of Dissolution of Corporation: ________________
Sale of Business
Date of the Sale: ___________ Transaction Privilege Tax# ______________
Name of New Owner: ___________________________________________________
Address: ______________________________________________________________
City: ______________ State: ________ Zip code: __________
Phone: _________________
Other (please specify): _______________________________________
Signature:
_____________________________________
Print Name:
_____________________________________
Title:
_____________________________________
(Corporate Officer, Partner, Owner)
Print and Mail form to: City of Mesa, Tax Audit & Collections, PO Box 1466, Mesa, AZ, 8211-1466.

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