Missouri Schedule A - Enterprise Zone: Application For Subsequently Claiming Tax Benefits
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1MISSOURI SCHEDULE
A
ENTERPRISE ZONE:
APPLICATION FOR SUBSEQUENTLY CLAIMING TAX BENEFITS
Read instructions carefully before completing form.
FOR CALENDAR YEAR
OR TAX YEAR BEGINNING
ENDING
NAME OF FACILITY
FACILITY FEDERAL ID NO.
AND
PLEASE
ADDRESS OF FACILITY (WHERE DEVELOPMENT OCCURRED)
TAXPAYER FEDERAL ID NO.
TYPE
OR
AND
PRINT
CITY
COUNTY
ZIP CODE
FACILITY MISSOURI TAX ID NO.
(MITS)
MISSOURI
FOLLOWING TO BE COMPLETED BY GOVERNING AUTHORITY’S REPRESENTATIVE, NOT TAXPAYER.
I, ____________________________________________________, of _______________________________________________,
(AUTHORIZED REPRESENTATIVE)
(CITY OR COUNTY)
a duly authorized representative of the governing authority of the foregoing city or county, do hereby certify on this
_______________ day of _________________________, ______________, that the foregoing facility’s address is within the
____________________________________________ Enterprise Zone’s:
(ENTERPRISE ZONE NAME)
(CHECK ONE)
Original boundaries designated on
___________________________________________________________________
OR
Expanded boundaries designated on
_________________________________________________________________
OR
Redesignated boundaries designated on
______________________________________________________________
SIGNATURE OF AUTHORIZED REPRESENTATIVE
MUST BE SIGNED IN
PRESENCE OF NOTARY
NOTARY PUBLIC EMBOSSER OR
STATE
COUNTY (OR CITY OF ST. LOUIS)
BLACK INK RUBBER STAMP
SEAL
SUBSCRIBED AND SWORN BEFORE ME, THIS
DAY OF
YEAR
USE RUBBER STAMP IN CLEAR AREA BELOW.
NOTARY PUBLIC SIGNATURE
MY COMMISSION EXPIRES
NOTARY PUBLIC NAME (TYPED OR PRINTED)
ATTACH TO FORM 135 ONLY. DO NOT FILE WITH FORM 135-A UNLESS YOUR ZONE WAS REDESIGNATED DURING THE
YEAR YOU ARE FILING.
MAIL TO:
FINANCE MANAGEMENT
MISSOURI DEPARTMENT OF ECONOMIC DEVELOPMENT
PO BOX 118
JEFFERSON CITY, MO 65102
Last Updated April 2006
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