MISSOURI DEPARTMENT OF PUBLIC SAFETY DIVISION OF ALCOHOL AND TOBACCO CONTROL P.O. BOX 837 JEFFERSON CITY, MISSOURI 65102 DATE APPLICATION FOR REFUND OF MISSOURI TAX NAME OF WHOLESALER ADDRESS CITY, STATE ZIP CODE holding State of Missouri Wholesale-Solicitor’s License No. __________________________________ hereby makes application for refund, for the value of Missouri tax paid, with the purpose of inducing the Legislature and Governor of the State of Missouri to make said refund and makes the following statements: NUMBER OF BOTTLES SIZE OF BOTTLES TAX RATE PER BOTTLE DESCRIPTION OF LIQUOR AMOUNT OF TAX TOTAL VALUE REASON FOR REFUND (CHECK ONE) DAMAGED WILL BE DESTROYED (MUST BE WITNESSED BY AGENT) TO BE RETURNED TO DISTILLER FOR PROCESSING UNFIT FOR CONSUMPTION (MUST BE SUPPORTED BY CERTIFICATE FROM HEALTH DEPARTMENT) OTHER (EXPLAIN BELOW) PROCEDURE FOR OBTAINING REFUND Claimant will execute claim for refund by first filling out page 1 of application with carbon on to pages 2, 3, and 4.Pages 2, 3, and 4 will then be sent to the Division of Alcohol and Tobacco Control in Jefferson City, Missouri. An agent will then be sent to the claimants premises to physically inspect the merchandise. The agent will then make a determination whether or not the claimants reason for refund is valid. If the claimant’s merchandise is to be destroyed, the agent must witness the destruction. If the merchandise is to be shipped out-of-state, a bill of lading and a copy of the invoice must be sent to the Division of Alcohol and Tobacco Control along with page 3 of the application. All claims for refunds must follow the provisions of Regulation 70.2.150 of the Rules and Regulations of the Supervisor of Alcohol and Tobacco Control which states “under no circumstances shall refund claims be accepted b y the Supervisor if the sole reason for their presentation to him/her is because the claimant has purchased beyond his/her capacity to sell,”or the merchandise has been removed from the State of Missouri before an agent of the Division of Alcohol and Tobacco Control has inspected the merchandise. LICENSEE INFORMATION/SIGNATURE NAME OF LICENSEE TO WHOM REFUND IS TO BE MADE ___________________________________________ upon his/her oath states that the facts set out are true. ADDRESS CITY, STATE, ZIP CODE PAGE 1 INSERT NAME OF LICENSEE/MANAGING OFFICER CLAIMING REFUND BELOW. SIGNATURE OF LICENSEE/MANAGING OFFICER WHOLESALER’S FILE COPY MO 812-0620N (11-03) American LegalNet, Inc. www.FormsWorkflow.com MISSOURI DEPARTMENT OF PUBLIC SAFETY DIVISION OF ALCOHOL AND TOBACCO CONTROL P.O. BOX 837 JEFFERSON CITY, MISSOURI 65102 DATE APPLICATION FOR REFUND OF MISSOURI TAX NAME OF WHOLESALER ADDRESS CITY, STATE ZIP CODE holding State of Missouri Wholesale-Solicitor’s License No. __________________________________ hereby makes application for refund, for the value of Missouri tax paid, with the purpose of inducing the Legislature and Governor of the State of Missouri to make said refund and makes the following statements: NUMBER OF BOTTLES SIZE OF BOTTLES TAX RATE PER BOTTLE DESCRIPTION OF LIQUOR AMOUNT OF TAX TOTAL VALUE REASON FOR REFUND (CHECK ONE) DAMAGED WILL BE DESTROYED (MUST BE WITNESSED BY AGENT) TO BE RETURNED TO DISTILLER FOR PROCESSING UNFIT FOR CONSUMPTION (MUST BE SUPPORTED BY CERTIFICATE FROM HEALTH DEPARTMENT) OTHER (EXPLAIN BELOW) AGENT USE ONLY I, ____________________________________________________ , Agent of the Division of Alcohol and Tobacco Control, State of Missouri, being duly sworn upon my oath state that on ______________________________________________ I examined the above merchandise and (check one) Approve Disapprove SIGNATURE OF AGENT the requested refund. DATE LICENSEE INFORMATION/SIGNATURE NAME OF LICENSEE TO WHOM REFUND IS TO BE MADE ___________________________________________ upon his/her oath states that the facts set out are true. ADDRESS CITY, STATE, ZIP CODE PAGE 2 INSERT NAME OF LICENSEE/MANAGING OFFICER CLAIMING REFUND BELOW. SIGNATURE OF LICENSEE/MANAGING OFFICER WHOLESALER’S COPY - TO BE RETAINED AFTER AGENT’S INSPECTION MO 812-0620N (11-03) American LegalNet, Inc. www.FormsWorkflow.com MISSOURI DEPARTMENT OF PUBLIC SAFETY DIVISION OF ALCOHOL AND TOBACCO CONTROL P.O. BOX 837 JEFFERSON CITY, MISSOURI 65102 DATE APPLICATION FOR REFUND OF MISSOURI TAX NAME OF WHOLESALER ADDRESS CITY, STATE ZIP CODE holding State of Missouri Wholesale-Solicitor’s License No. __________________________________ hereby makes application for refund, for the value of Missouri tax paid, with the purpose of inducing the Legislature and Governor of the State of Missouri to make said refund and makes the following statements: NUMBER OF BOTTLES SIZE OF BOTTLES TAX RATE PER BOTTLE DESCRIPTION OF LIQUOR AMOUNT OF TAX TOTAL VALUE REASON FOR REFUND (CHECK ONE) DAMAGED WILL BE DESTROYED (MUST BE WITNESSED BY AGENT) TO BE RETURNED TO DISTILLER FOR PROCESSING UNFIT FOR CONSUMPTION (MUST BE SUPPORTED BY CERTIFICATE FROM HEALTH DEPARTMENT) OTHER (EXPLAIN BELOW) AGENT USE ONLY I, ____________________________________________________ , Agent of the Division of Alcohol and Tobacco Control, State of Missouri, being duly sworn upon my oath state that on ______________________________________________ I examined the above merchandise and (check one) SIGNATURE OF AGENT Approve Disapprove the requested refund. DATE LICENSEE INFORMATION/SIGNATURE NAME OF LICENSEE TO WHOM REFUND IS TO BE MADE ___________________________________________ upon his/her oath states that the facts set out are true. ADDRESS CITY, STATE, ZIP CODE PAGE 3 INSERT NAME OF LICENSEE/MANAGING OFFICER CLAIMING REFUND BELOW. WHOLESALER’S COPY - MO 812-0620N (11-03) SIGNATURE OF LICENSEE/MANAGING OFFICER TO BE RETURNED TO DIVISION OF ALCOHOL AND TOBACCO CONTROL (AFTER AGENT’S INSPECTION) WITH COPIES OF INVOICE AND BILL OF LADING, IF APPLICABLE. American LegalNet, Inc. www.FormsWorkflow.com MISSOURI DEPARTMENT OF PUBLIC SAFETY DIVISION OF ALCOHOL AND TOBACCO CONTROL P.O. BOX 837 JEFFERSON CITY, MISSOURI 65102 DATE APPLICATION FOR REFUND OF MISSOURI TAX NAME OF WHOLESALER ADDRESS CITY, STATE ZIP CODE holding State of Missouri Wholesale-Solicitor’s License No. __________________________________ hereby makes application for refund, for the value of Missouri tax paid, with the purpose of inducing the Legislature and Governor of the State of Missouri to make said refund and makes the following statements: NUMBER OF BOTTLES SIZE OF BOTTLES TAX RATE PER BOTTLE DESCRIPTION OF LIQUOR AMOUNT OF TAX TOTAL VALUE REASON FOR REFUND (CHECK ONE) DAMAGED WILL BE DESTROYED (MUST BE WITNESSED BY AGENT) TO BE RETURNED TO DISTILLER FOR PROCESSING UNFIT FOR CONSUMPTION (MUST BE SUPPORTED BY CERTIFICATE FROM HEALTH DEPARTMENT) OTHER (EXPLAIN BELOW) AGENT USE ONLY I, ____________________________________________________ , Agent of the Division of Alcohol and Tobacco Control, State of Missouri, being duly sworn upon my oath state that on ______________________________________________ I examined the above merchandise and (check one) SIGNATURE OF AGENT Approve the requested refund. Disapprove DATE LICENSEE INFORMATION/SIGNATURE NAME OF LICENSEE TO WHOM REFUND IS TO BE MADE ___________________________________________ upon his/her oath states that the facts set out are true. ADDRESS CITY, STATE, ZIP CODE PAGE 4 INSERT NAME OF LICENSEE/MANAGING OFFICER CLAIMING REFUND BELOW. SIGNATURE OF LICENSEE/MANAGING OFFICER AGENT’S COPY MO 812-0620N (11-03) American LegalNet, Inc. www.FormsWorkflow.com