Fillable Form 126e - Missouri Tax Exemption Change Request printable pdf download

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MISSOURI DEPARTMENT OF REVENUE

TAXATION DIVISION

DLN (DOR USE ONLY)

FORM

PO BOX 358, JEFFERSON CITY, MO 65105

126E

PHONE: 573-751-2836

FAX: 573-751-9409

E-MAIL: SALESTAXEXEMPTIONS@DOR.MO.GOV

(REV. 04-2011)

MISSOURI TAX EXEMPTION CHANGE REQUEST

PLEASE USE THIS FORM TO MAKE CHANGES TO YOUR MISSOURI SALES/USE TAX EXEMPTION ACCOUNT. PLEASE TYPE OR PRINT.

MISSOURI TAX I.D. NUMBER

____ ____ ____ ____ ____ ____ ____ ____

FEDERAL EMPLOYER I.D. NUMBER

____ ____ ____ ____ ____ ____ ____ ____ ____

INFORMATION CURRENTLY ON FILE WITH THE DEPARTMENT OF REVENUE

ORGANIZATION OR AGENCY NAME

PHONE

(___ ___ ___) ___ ___ ___ - ___ ___ ___ ___

ORGANIZATION OR AGENCY STREET ADDRESS

CITY

STATE

ZIP CODE

COUNTY

___ ___ ___ ___ ___

PLEASE MAKE THE FOLLOWING CHANGE(S) TO MY MISSOURI TAX EXEMPTION ACCOUNT

ORGANIZATION OR AGENCY NAME CHANGE (NOTE: IF ORGANIZATION IS INCORPORATED NAME MUST BE CHANGED WITH THE MISSOURI

SECRETARY OF STATE’S OFFICE BEFORE THE ACCOUNT CAN BE UPDATED)

NEW ORGANIZATION OR AGENCY NAME ___________________________________________________________________________________

CHANGE THE ORGANIZATION OR AGENCY PHYSICAL ADDRESS (THIS IS THE ADDRESS THAT WILL APPEAR ON THE EXEMPTION LETTER)

STREET ADDRESS-DO NOT USE P.O. BOX OR RURAL ROUTE _________________________________________________________________

CITY __________________________________________

STATE ________

ZIP CODE ______________

COUNTY __________________

PHONE NUMBER __________________________________________

CHANGE MAILING ADDRESS

STREET ADDRESS OR P.O. BOX __________________________________________________________________________________________

CITY __________________________________________

STATE ________

ZIP CODE ______________

COUNTY __________________

ORGANIZATION OR AGENCY OFFICER CHANGE(S) TO MY MISSOURI TAX EXEMPTION ACCOUNT

NOTE: ONLY OFFICERS OF THE ORGANIZATION CAN BE ADDED TO THE ACCOUNT. ALL OTHER PERSONS MUST OBTAIN A MISSOURI POWER OF

ATTORNEY, FORM 2827, at

NAME (LAST, FIRST, MIDDLE INITIAL)

TITLE

HOME ADDRESS

CITY

STATE

ZIP CODE

ADD

___ ___ ___ ___ ___

DELETE

BIRTHDATE

SOCIAL SECURITY NUMBER

TERM EFFECTIVE DATE/TERM END DATE

___ ___ / ___ ___ / ___ ___ ___ ___

___ ___ ___ - ___ ___ - ___ ___ ___ ___

___ ___ / ___ ___ / ___ ___ ___ ___

NAME (LAST, FIRST, MIDDLE INITIAL)

TITLE

HOME ADDRESS

CITY

STATE

ZIP CODE

ADD

___ ___ ___ ___ ___

DELETE

BIRTHDATE

SOCIAL SECURITY NUMBER

TERM EFFECTIVE DATE/TERM END DATE

___ ___ / ___ ___ / ___ ___ ___ ___

___ ___ ___ - ___ ___ - ___ ___ ___ ___

___ ___ / ___ ___ / ___ ___ ___ ___

NAME (LAST, FIRST, MIDDLE INITIAL)

TITLE

ADD

HOME ADDRESS

CITY

STATE

ZIP CODE

___ ___ ___ ___ ___

DELETE

BIRTHDATE

SOCIAL SECURITY NUMBER

TERM EFFECTIVE DATE/TERM END DATE

___ ___ / ___ ___ / ___ ___ ___ ___

___ ___ ___ - ___ ___ - ___ ___ ___ ___

___ ___ / ___ ___ / ___ ___ ___ ___

COMMENTS:

I swear or affirm that the information reported in this form and any attached supplements is true and correct as to every material matter; that the present nature, purpose and

activities of the above-named organization or agency are the same as they were when the attached documents were issued and will continue to remain the same; that I will

remain knowledgeable of the statutes and regulations governing sales/use tax exemptions and that I will immediately notify the Missouri Department of Revenue, of any change

in circumstances which could reasonably lead me to believe that the above-named organization or agency would no longer qualify as exempt, either because of a change in the

law or because of a material change in the organization’s or agency’s nature, purpose or activities. It is understood that any misrepresentation contained herein or failure on my

part to fulfill the promises entered into here will result in the immediate revocation of any exemption letter issued to this organization or agency. I also declare under penalties of

perjury that I employ no illegal or unauthorized aliens as defined under federal law and that I am not eligible for any tax exemption, credit or abatement if I employ such aliens.

SIGNATURE

TITLE

DATE

___ ___ / ___ ___ / ___ ___ ___ ___

PRINT NAME

E-MAIL ADDRESS

DOR-126E (04-2011)

No digital signatures allowed