Application to Share in Flora Farms' Refund of Unconstitutional Taxes

Notice: Under Missouri statues, any sales tax refunds belong to the retailer who was forced to collect, account for, and remit those taxes to the state with monthly tax return paperwork. This form is for internal use by Flora Farms voluntarily share with our customers the proceeds of its refund for the unconstitutional taxes.

1) Customer & Patient Information

FULL NAME*
As it appears on State-based ID or Medical Marijuana Card

FLORA FARMS LOYALTY ID (Optional)

2) Claim Verification

Eligibility Period: October 1, 2023 - July 22, 2025

DISPENSARY LOCATION(S)*

To be completed by Customer using original or digital receipts:

TOTAL NUMBER OF RECEIPTS ATTACHED*

Please enter a number from 1 to 250.

RECEIPT UPLOAD*

Accepted files types: jpeg, pdf

3) Privacy & Records Acknowledgement

In compliance with state medical privacy regulations and Flora Farms’ Data Security Policy, I acknowledge that:

Flora Farms 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) to help quantify the amount that Flora Farms might voluntarily share from its refund.

NOTICE: PROTECTING PATIENT & CUSTOMER PRIVACY

Regarding Record Requests
In light of the recent Missouri Supreme Court ruling, Flora Farms 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, Flora Farms 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 will show what taxes you paid.
• Digital Receipts: Check your registered email for receipts sent from our Point-of-Sale or Kiosk systems. These are also acceptable to establish what taxes you paid.

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.

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 and that I have not falsified or otherwise submitted any fraudulent information about my purchase history at Flora Farms Dispensaries. We will review all requests for voluntary shares of Flora Farms' tax refund and inform you of our decision. Please note that the process and the issuance of said credit may take approximately 30 days from the date this form is received.

HAVE QUESTIONS?

Have questions? Please send an email to [email protected] with your Full Name in the subject line, and we will review it as soon as possible. Please note that it could take us up to 30 days to respond.

SUBMISSION DATE*

CONSENT