Tax Clearance - Special Event Request

Business Owner Information

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

EIN:

00-0000000

Business Name:

Doing Business As (DBA):

if different than Business Name

Individual Submitting this Request:

if different from the Taxpayer

Relationship or Authority:

KDOR Affiliate Code:

Taxpayer's Email Address:

Is the Business Address same as above address?

YesNo

Daytime Phone:

000-000-0000

Daytime Phone Extension:

Fax Number:

000-000-0000

Event for Tax Clearance request:

Does the business make retail sales in Kansas?

YesNo

Other Events Attended in Kansas (include years attended)

1000 characters or fewer.

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.

By checking this box, approve the Kansas Department of Revenue to submit a copy of my tax clearance letter to the event named above.