Form 2879 - Irrevocable Letter Of Credit Form - State Of Missouri Page 2
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1
2Subscribed and sworn before me, this
Embosser or black ink rubber stamp seal
day of
year
State
County (or City of St. Louis)
My Commission Expires
Notary Public Signature
Notary Public Name (Typed or Printed)
The following Authorization for Release of Confidential Information has been set forth at the request of the Missouri Department
of Revenue and does not constitute a part of, or an exhibit to, the Irrevocable Letter of Credit on the reverse side of this form
.
I hereby authorize release of confidential tax information to ______________________________________________________
(Bank or Financial Institution)
for the purpose of making demand for payment on Irrevocable Letter of Credit Number ________________________________
as long as the obligation remains in force and effect. Release of this information to the named banking institution does not give the
banking institution authority to request information other than information concerning the delinquent periods for which a demand for
payment is being made. I also release the Director of Revenue and Department of Revenue personnel from any
and all liability pursuant to any disclosure of confidential tax information that is necessary for making demand for or receiving such
payment. By signing this Authorization, I state that I have the legal authority to bind the taxpayer or business below.
In witness whereof, this taxpayer or business duly executed the foregoing this ______ day of _________________, 20 ______.
Signature of Owner, Partner, Corporate Officer, or Member
Typed or Printed Name of Person Signing this Release
Title
Date (MM/DD/YYYY)
___ ___ / ___ ___ / ___ ___ ___ ___
Form 2879 (Revised 02-2015)
Mail to:
Sales and Use or Transient Employer
Withholding Tax
Motor Fuel Tax
Cigarette Tax
Other Tobacco Products
Taxation Division
Taxation Division
Taxation Division
Taxation Division
P.O. Box 357
P.O. Box 300
P.O. Box 811
P.O. Box 3320
Jefferson City, MO 65105-0357
Jefferson City MO 65105-0300
Jefferson City MO 65105-0811
Jefferson City, MO 65105-3320
Phone: (573) 751-5860
Phone: (573) 751-2611
Phone: (573) 751-7163
Phone: (573) 751-5772
Fax: (573) 522-1722
Fax: (573) 522-1720
Fax: (573) 522-1720
Fax: (573) 522-1720
E-mail:
businesstaxregister@dor.mo.gov
E-mail:
excise@dor.mo.gov
E-mail:
excise@dor.mo.gov
E-mail:
excise@dor.mo.gov
Visit
for additional information. TTY (800) 735-2966
*14608020001*
14608020001
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