MISSOURI FORM
135
NEW/EXPANDED BUSINESS FACILITY (HEADQUARTERS):
APPLICATION FOR INITIALLY CLAIMING TAX BENEFITS
Read instructions carefully before completing form.
Schedules S and M must accompany this application which must be filed in tax period after development occurred.
OR TA X Y EAR BEGINNING
FOR CALENDAR Y EAR
ENDING
NAME OF FACILITY
FACILITY FEDERAL ID NO.
AND
ADDRESS OF FACILITY (WHERE DEVELOPMENT OCCURRED)
TAXPAYER FEDERAL ID NO.
AND
CITY
COUNTY
ZIP CODE
FACILITY MISSOURI
TAX ID NO. ( MITS)
MISSOURI
Name and mailing address if different than above:
1.
NAME
ADDRESS (STREET, PO BOX, CITY, STATE, ZIP CODE)
1a. Name and address of other business facilities, if different from above:
PLEASE
TYPE OR
PRINT
2.
Name, address and telephone of person completing application:
NAME
Email Address
TELEPHONE NUMBER
(
)
ADDRESS (STREET, PO BOX, CITY, STATE, ZIP CODE)
YES NO
Has the company ever been convicted of a violation of the laws of any state and, or federal law?
If yes, provide the date, the Court, the charges at disposition and the case number.
Has the “principal” (Chiefs Executive Offi c er, Chief Financial Offi c er, Principal, Managing Partner and, or Owner) ever been convi c ted of a
YES NO
violation of the laws of any state and, or federal law?
If yes, provide the date, the Court, the charges at disposition and the case number.
YES NO
Has the “contact” ever been convicted of a violation of the laws of any state and, or federal law?
If yes, provide the date, the Court, the charges at disposition and the case number.
3.
Business entity f or tax purposes:
Corporation
Fiduciary
Indiv idual Proprietorship
Partnership
3a.
3b.
3c.
3d.
S-Corp.
Limited Liability
Limited Liability
Other (Specify)
3e.
3f.
3g.
3h.
Corp.
Partnership
_______ _____ ______
NOTE: IF THE TAXPAY ER IS A FIDUCIARY , PARTNERSHIP, S-CORPORATION, ETC., IDENTIFY THE NAMES, SOCIAL SECURITY NUMBERS AND
PROPORTIONED SHARE OF OWNERSHIP OF EACH BENEFICIARY , PARTNER OR SHAREHOLDER ON THE LAS T D AY OF THE TAX PERIOD.
AGGREGA TE PROPOR TIONATE SHARES OR PERCENTAGE OF TO TAL OWNERSHIP MAY NOT E XCEED 100%. ATTACH A SEPARA TE SHEE T IF
NECESSARY .
NAME(S)
SOCIAL SECURITY NO.(S)
%OWNERSHIP Y EAR END
%
%
%
%
3i.
Taxpayer’s total annual Missouri sales revenues or receipts:
$0 - $250,000
$250,000 - $500,000
$500,000 - $1M
$1M - $5M
$5M - $10M
$10M and ov er
3j.
Taxpayer’s total Missouri employment (total number of
employees):
Updated 01/2015