Date Submitted ______
Date Approved ______
License # ______
Period ______
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Affidavit of Application to Make Retail Sales in Parkville
As of January 1, 2009, the State of Missouri requires the possession of a “no tax due” statement from the Department
of Revenue stating no tax is due under sections 143.191 to 143.265, RSM0, (withholding tax) or sections 144.010 to
144.510, RSMo, (sales tax) prior to issuance or renewal of any city or county occupation license or any state license
required for conducting any business where goods are sold at retail.
Accordingly, with the exception of businesses that may be approved following receipt of the affidavit below, all
businesses applying for an occupational / business license in the City of Parkville must provide a current “no tax due”
statement at the time of application or renewal.
Businesses not located in the City of Parkville who have a valid Missouri Tax ID Number issued by the Missouri
Department of Revenue and who have made application to amended said license to allow taxable sales in the City of
Parkville may be issued a license following the acceptance of the following affidavit.
Affidavit Statement
Before me, the undersigned authority, personally appeared (Name of Affiant) who, being duly sworn on this oath
states as follows:
My name is ____________________________________________ , and I am the ____________________________
(Name) (Title)
of _____________________________________________________________________________________________.
(Legal Name of Business)
I am of legal age and sound mind, capable of making this affidavit and hereby certify and affirm by my signature that I
am authorized to do so. I am personally acquainted with the facts herein stated and understand that by submitting
this affidavit to the City of Parkville I am stating that:
• said business has a valid Missouri Tax ID Number, #_________________, issued by Missouri Department
of Revenue;
• that an application to amend said license to make taxable sales in the City of Parkville has been submitted
to the Missouri Department of Revenue;
• the “Taxable Sales/Taxable Purchases Begin Date” on said application is ________________________; and
• no taxable sales have or will be made in the City of Parkville prior to said Taxable Sales/Taxable Purchases
Begin Date.
Affidavit Acknowledgement and Authorization Signatures
I, the undersigned, do hereby authorize the submittal of this affidavit and any associated documents and certify and
affirm by my signature that all information I have provided herein is true and correct. I understand that providing
false or fraudulent information on this affidavit is unlawful under Parkville Municipal Code, Title II, Article IV,
Sections 215.550 and 215.560 and Title VI, Section 605.110, and shall be a violation punishable by penalties not
exceeding a fine of five hundred dollars ($500.00) and costs, or imprisonment for a term not exceeding ninety (90)
days, or both such fine and imprisonment. I further understand that each day in which any violation of any of the
provisions of Parkville Municipal Code shall occur shall constitute a separate offense.
Affiant signature: ______________________________________________________________________________ Date: ______________
