Form 2879 - Irrevocable Letter Of Credit Page 2
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1
2THE AREA BELOW IS TO BE USED BY THE BANK FOR ENDORSING THIS IRREVOCABLE LETTER OF CREDIT
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.
MISSOURI DEPARTMENT OF REVENUE
AUTHORIZATION FOR RELEASE OF CONFIDENTIAL INFORMATION
I hereby authorize release of confidential tax information to
(BANK/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/business below.
In witness whereof, this taxpayer/business duly executed the foregoing this
day of
, 20
.
TAXPAYER/BUSINESS (OWNER, PARTNER, CORPORATE OFFICER OR MEMBER)
TITLE
SIGNATURE OF OWNER, PARTNER, CORPORATE OFFICER, OR MEMBER
PRINT OR TYPE NAME OF PERSON SIGNING THIS RELEASE
NOTARY PUBLIC
NOTARY PUBLIC EMBOSSER OR
STATE
COUNTY (OR CITY OF ST. LOUIS)
BLACK INK RUBBER STAMP SEAL
SUBSCRIBED AND SWORN BEFORE ME, THIS
USE RUBBER STAMP IN CLEAR AREA BELOW.
DAY OF
20
NOTARY PUBLIC SIGNATURE
MY COMMISSION
EXPIRES
NOTARY PUBLIC NAME (TYPED OR PRINTED)
This publication is available upon request in alternative accessible format(s). TDD 1-800-735-2966
MO 860-1820 (11-2008)
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