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

Business Information

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.

Submission Verification and Agreement

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. *

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