Form 4098 - Application For Direct Pay Authorization
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1.
MISSOURI DEPARTMENT OF REVENUE
FORM
TAXATION DIVISION
4098
APPLICATION FOR DIRECT
(REV. 10-2007)
PAY AUTHORIZATION
This application is to be used for applying for or renewing the direct pay exemption authorization pursuant to Section 144.190.4, RSMo. This
authorization, if issued, is valid for five (5) years.
PLEASE PRINT OR TYPE AND COMPLETE ALL LINES — Do not write in shaded areas. Mail completed application or direct questions to:
Missouri Department of Revenue, Taxation Division, P.O. Box 358, Jefferson City, MO 65105-0358 or call (573) 751-2836.
2. YOUR MISSOURI TAX IDENTIFICATION NUMBER
3. EFFECTIVE DATE
EXPIRATION DATE
M
M
D
D
C
C
Y
Y
M
M
D
D
C
C
Y
Y
4. TYPE OF APPLICATION
CODE
NEW
RENEWAL
5. PRIMARY BUSINESS LOCATION
BUSINESS TRADE NAME
BUSINESS PHONE (AREA CODE & NUMBER)
(
)
STREET ADDRESS (DO NOT USE P.O. BOX OR RURAL ROUTE)
COUNTY
CODE
CITY
CODE
STATE ZIP CODE
6. OWNER NAME AND ADDRESS
OWNER NAME
STREET OR RURAL ROUTE, P.O. BOX NUMBER
COUNTY
CODE
CITY
CODE
STATE ZIP CODE
1
2
3
7. MAILING ADDRESS
BUSINESS ADDRESS
OWNER ADDRESS
OTHER (GIVE FULL ADDRESS BELOW):
STREET ADDRESS OR P.O. BOX
CITY
STATE ZIP CODE
COUNTY
CODE
8. ADDRESS WHERE BOOKS AND RECORDS ARE KEPT
1
2
3
4
BUSINESS ADDRESS
OWNER ADDRESS
MAILING ADDRESS
OTHER (GIVE FULL ADDRESS BELOW):
STREET ADDRESS - DO NOT USE P.O. BOX OR RURAL ROUTE
CITY
STATE ZIP CODE
COUNTY
CODE
9. Sales Tax Rule 12 CSR 10-104.040 provides in part that records must be submitted to demonstrate that the business or
corporation annually purchases non-resalable items in excess of seven hundred fifty thousand dollars ($750,000).
Attach invoices, statements, etc.
This publication is available upon request in alternative accessible format(s).
MO 860-2350 (10-2007)
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