Tax Clearance - Individual Income Request

Social Security Number:

000-00-0000

First Name:

Middle Initial:

Last Name:

Date of Birth:

mm/dd/yyyy

Street 1:

Street 2:

City:

State:

Zip Code:

00000-0000

Daytime Phone:

000-000-0000

Daytime Phone Extension:

Fax Number:

000-000-0000

Have you filed Kansas Individual Income Tax returns with the Department of Revenue for the following tax years?

2022

YesNo

2021

YesNo

2020

YesNo

Reason for Tax Clearance request:

Individual Submitting this Request (if Different from the Taxpayer):

Relationship or Authority:

KDOR Affiliate Code:

Taxpayer's Email Address:

By checking this box, I declare under penalties of perjury that, to the best of my knowledge and belief, the above information is true and correct.