Form 100 - Verification Of Contribution To Development And Reserve Fund, Infrastructure 100 Development Fund, Or Export Finance Fund - Missouri Development Finance Board
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1MISSOURI FORM
Missouri Development Finance Board
VERIFICATION OF CONTRIBUTION TO
100
DEVELOPMENT AND RESERVE FUND, INFRASTRUCTURE
Section 100.286.6 RSMo
DEVELOPMENT FUND, OR EXPORT FINANCE FUND
PLEASE PRINT OR TYPE
APPLICATION MUST BE APPROVED PRIOR TO DUE DATE OF TAX RETURN
SECTION 1
CONTRIBUTOR / CONTRIBUTION
1
INDIVIDUAL’S NAME OR NAME OF BUSINESS MAKING CONTRIBUTION
Attention:
2
ADDRESS (STREET / P.O. BOX, CITY, STATE, ZIP CODE)
3
INDIVIDUAL OR BUSINESS TAX YEAR
BEGINNING DATE
ENDING DATE
CALENDAR YEAR
FISCAL YEAR
TAXPAYER TYPE
4
BUSINESS FEDERAL IDENTIFICATION NUMBER
If the taxpayer is a Fiduciary, Partnership or
Corporation
Fiduciary
S-Corporation, attach a separate sheet to this
application and identify the names, social security
Partnership
S-Corp
numbers, and proportioned share of ownership of
SOCIAL SECURITY NUMBER(S)
each beneficiary, partner or shareholder.
Individual
Aggregate proportionate shares or percent of
Individual Proprietorship
ownership may not exceed 100%.
MISSOURI TAX IDENTIFICATION NUMBER
AMOUNT OF THE CONTRIBUTION
5
6
DATE CONTRIBUTION WAS MADE
(In the case of marketable securities, the amount of
contribution equals the net liquidated proceeds.)
$
SECTION 2
DESIGNATED FUND
7
TO WHICH FUND DID YOU MAKE THE CONTRIBUTION? (CHECK ONLY ONE)
DEVELOPMENT AND RESERVE FUND
X
INFRASTRUCTURE DEVELOPMENT FUND (IDF)
PROJECT NAME
EXPORT FINANCE FUND
SECTION 3
VERIFICATION OF CONTRIBUTION
I do hereby certify, subject to the penalties of perjury, that a contribution was made to the above-identified Fund by the subject taxpayer on the
date and in the amount indicated above.
SIGNATURE OF CONTRIBUTOR
DATE
4
SECTION 4
TO BE COMPLETED BY MISSOURI DEVELOPMENT FINANCE BOARD
OFFICIAL USE ONLY
I have examined this application (including all attachments, and do hereby acknowledge receipt of the contribution as specified in Section 1) and
to the best of my knowledge and belief, it is true, correct and complete.
SIGNATURE OF MISSOURI DEVELOPMENT FINANCE BOARD REPRESENTATIVE
DATE
RETURN COMPLETED FORM AND CONTRIBUTION TO:
MISSOURI DEVELOPMENT FINANCE BOARD
P. O. BOX 567 / 200 MADISON ST., STE. 1000
JEFFERSON CITY, MO 65102
(573) 751-8479
MO 419-1701 (10-94)
D63968 04/26/99
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