Greenlight Dispensary • Missouri

Local Tax Correction: Claim & Release

Notice: This form is for internal use by Greenlight Missouri customers to claim a direct credit of unconstitutionally collected local taxes per the Missouri Supreme Court ruling (July 2025). This form is in lieu of MO Form 472P for direct in-house processing.

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1) CUSTOMER & PATIENT INFORMATION
FULL NAME*
As it appears on State-based ID or Medical Marijuana Card

2) CLAIM VERIFICATION
Eligibiity Period: October 1, 2023 - July 22, 2025
Dispensary Location(s)*
To be completed by Customer using original or digital receipts:
Please enter a number from 1 to 250.
Drop files here or
Accepted file types: jpg, gif, png, pdf, Max. file size: 50 MB, Max. files: 250.

    3) PRIVACY & RECORDS ACKNOWLEDGMENT
    In compliance with state medical privacy regulations and Greenlight’s Data Security Policy, I acknowledge that:
    • Greenlight does not provide bulk transaction history or printed purchase summaries at retail counters to protect patient and customer privacy.
    • I have provided my own physical or digital receipts (issued at the time of sale) as the sole evidence for this claim.

      NOTICE: PROTECTING PATIENT & CUSTOMER PRIVACY
      Regarding Record Requests
      In light of the recent Missouri Supreme Court ruling, Greenlight is dedicated to helping our community secure their 3% tax credits. However, to ensure the highest level of Data Security and to remain in strict compliance with Medical Privacy Regulations, Greenlight will not issue bulk transaction history reports at our retail counters.

      Why we do this:
      • Physical Receipts: The original receipt issued at the time of sale contains the exact tax breakdown required for your credits.
      • Digital Receipts: Check your registered email for receipts sent from our Point-of-Sale or Kiosk systems. These are recognized as valid proof of purchase for all credit claims.

      How to Access Your Proof of Purchase:To file your claim, please utilize the records already in your possession
      • Privacy Protection: Your purchase history is sensitive. Printing these records in a retail environment poses a risk to your personal and medical data security.
      • HIPAA Standards: For our medical patients, we maintain the highest standards of confidentiality and avoid the unauthorized distribution of historical purchase data.

      Thank you for helping us keep your personal information safe and secure.

      4) LEGAL RELEASE & AFFIDAVIT (PLEASE READ CAREFULLY)
      By submitting this document, I hereby attest that I am the rightful purchaser for the transactions submitted. Greenlight Dispensary shall initiate a process to review requests, confirm validity, and apply any applicable credit. Please note that the process and the issuance of said credit may take up to 30 days from the date this form is received.
      MM slash DD slash YYYY
      Consent