Form Mo 419-1524 - Missouri Schedule A - Certification Of Facility Location printable pdf download

Form Mo 419-1524 - Missouri Schedule A - Certification Of Facility Location

MISSOURI SCHEDULE

MISSOURI DEPARTMENT OF ECONOMIC DEVELOPMENT

ENTERPRISE ZONE:

CERTIFICATION OF FACILITY LOCATION

READ PAGES 28-29 OF INSTRUCTIONS CAREFULLY BEFORE COMPLETING FORM

FOR CALENDAR YEAR _____ OR TAX YEAR BEGINNING __________________ _____, _____, ENDING ________________ _____, _____

THIS SCHEDULE IS TO BE COMPLETED ONLY BY TAXPAYERS INITIALLY CLAIMING ENTERPRISE ZONE TAX BENEFITS AND IS

TO BE ATTACHED TO FORM 135 (DO NOT COMPLETE SCHEDULE A IF YOU ARE FILING FORM 135-A UNLESS YOUR ZONE WAS

REDESIGNATED DURING THE YEAR YOU ARE FILING).

NAME OF FACILITY

FACILITY FEDERAL I.D. NO.

AND

ADDRESS OF FACILITY (WHERE DEVELOPMENT OCCURRED)

STREET

TAXPAYER FEDERAL I.D. NO.

AND

CITY

COUNTY

ZIP CODE

FACILITY MISSOURI TAX I.D. NO.

(MITS)

MISSOURI

FOLLOWING TO BE COMPLETED BY GOVERNING AUTHORITY’S REPRESENTATIVE, NOT TAXPAYER (See instructions, pages

28-29):

I, _____________________________________________ , of ________________________________________________ ,

(AUTHORIZED REPRESENTATIVE)

(CITY OR COUNTY)

a duly authorized representative of the governing authority of the foregoing city or county, do hereby certify on this

_______________ day of __________________________ , _______ , that the foregoing facility’s address is within the

___________________________________________________ Enterprise Zone’s:

(ENTERPRISE ZONE NAME)

(CHECK ONE) (See instructions, pages 27-28):

Original boundaries designated on __________________________________________________________ , _________

Expanded boundaries designated on ________________________________________________________ , _________

Redesignated boundaries designated on _____________________________________________________ , _________

SIGNATURE OF AUTHORIZED REPRESENTATIVE

MUST BE SIGNED IN

❿

PRESENCE OF NOTARY

NOTARY PUBLIC EMBOSSER OR

STATE

COUNTY (OR CITY OF ST. LOUIS)

BLACK INK RUBBER STAMP SEAL

SUBSCRIBED AND SWORN BEFORE ME, THIS

DAY OF

YEAR

USE RUBBER STAMP IN CLEAR AREA BELOW.

NOTARY PUBLIC SIGNATURE

MY COMMISSION

EXPIRES

NOTARY PUBLIC NAME (TYPED OR PRINTED)

ATTACH TO FORM 135 ONLY. DO NOT FILE WITH FORM 135-A UNLESS YOUR ZONE WAS REDESIGNATED DURING THE YEAR

YOU ARE FILING.

MAIL TO: FINANCIAL SERVICES SECTION, MISSOURI DEPARTMENT OF ECONOMIC DEVELOPMENT, P.O. BOX 118,

JEFFERSON CITY, MISSOURI 65102.

MO 419-1524 (11-04)

Form Mo 419-1524 - Missouri Schedule A - Certification Of Facility Location

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