Form 4102 - Application For Release Of Certificate Of Deposit
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MISSOURI DEPARTMENT OF REVENUE
CUSTOMER SERVICES DIVISION
4102
P.O. BOX 357 JEFFERSON CITY, MO 65105-0357
APPLICATION FOR RELEASE OF
(REV. 01-2008)
CERTIFICATE OF DEPOSIT
This application must be completed and mailed to the above address in order to initiate the release of the Certificate of Deposit. The
Certificate of Deposit may be released by the Department of Revenue upon completion of a two (2) year period of satisfactory tax
compliance. Satisfactory tax compliance shall mean that for a period of two (2) consecutive years immediately preceding application for
release of the bond, the taxpayer has filed all returns and paid all taxes, additions and interest due on a timely basis. The Certificate of
Deposit may also be released within 30 days, when the taxpayer ceases to do business, files a final return with the Director of Revenue
and pays all tax, additions and interest. This application should be filed with the Director of Revenue sixty (60) days prior to the maturity
date of the Certificate of Deposit.
MISSOURI TAX ID NUMBER
___ ___ ___ ___ ___ ___ ___ ___
OWNER NAME
DAYTIME TELEPHONE
(___ ___ ___) ___ ___ ___ - ___ ___ ___ ___
MAILING ADDRESS, CITY, STATE, ZIP CODE
AMOUNT OF CERTIFICATE OF DEPOSIT
DATE CERTIFICATE OF DEPOSIT WAS ISSUED
$
___ ___ / ___ ___ / ___ ___ ___ ___
Release of Certificate of Deposit is requested for the following reason (check box):
Bond has been filed for the required 2 year period with a satisfactory tax compliance.
Sold or quit business on
MONTH
DAY
YEAR
Business never opened.
Other (Explain)
I swear or affirm that all returns have been filed and paid, that there are no outstanding liabilities, and that the information reported in
this form and any attached supplements is true, correct and complete.
SIGNATURE OF OWNER, PARTNER OR OFFICER OF CORPORATION
TITLE
DATE
__ __ / __ __ / __ __ __ __
DEPARTMENT USE ONLY
APPROVED: The above taxpayer has been released from the bond requirement and the attached Certificate of Deposit is being
returned. In order to cash the Certificate of Deposit, this Application for Release of Certificate of Deposit must be
submitted to the issuing financial institution with the Certificate of Deposit.
DENIED:
Your request has been denied for the following reason:
Bond has not been filed for 2 years
A satisfactory tax compliance record has not been established for the last 2 years.
Final return and payment have not been received
Other:
AUTHORIZED SIGNATURE
TITLE
DATE
__ __ / __ __ / __ __ __ __
This publication is available upon request in alternative accessible format(s).
MO 860-2353 (01-2008)
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