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. *