Form 4458 - Business Activity Questionnaire Page 3
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4FORM 4458
PAGE 3
YES
NO
20. Do your employees, associates, or representatives periodically or occasionally service or repair equipment, or property of
your customers in this state?
21. Do your employees, associates, or representatives perform any installation or construction work within this state?
22. Do your employees, associates, or representatives supervise or inspect the installation of products sold to your
customers in this state?
23. Amount of salaries, commissions, or wages paid for services performed by employees, associates, or
representatives in the last four years:
Total
Total
Year Ending
Everywhere
Missouri
20 ____
$_____________
$_____________
20 ____
$_____________
$_____________
20 ____
$_____________
$_____________
20 ____
$_____________
$_____________
24. Names, addresses and social security numbers of five highest paid Missouri representatives:
Name
Address
Social Security Number (required)
a)
b)
c)
d)
e)
25. Amount of gross receipts from the sale of tangible, intangible and the sale of services during the last four years:
From points in
From points in
From points outside
Year
MO to points
MO to points
MO to points
Ended
in MO
outside MO
in MO
20 ____
$_____________
$_____________
$_____________
20 ____
$_____________
$_____________
$_____________
20 ____
$_____________
$_____________
$_____________
20 ____
$_____________
$_____________
$_____________
26. How are sales made in this state?
Internet
Salesperson
Phone
Other _____________________________
27. List names and addresses of your five largest customers in Missouri:
Name
Address
a)
b)
c)
d)
e)
28. Enclose a signed copy of the front page of your federal income tax return (consolidated return if applicable) for the last four years as
reported to the Internal Revenue Service.
Under penalties of perjury, I declare the information furnished in this questionnaire is true, correct and complete to the best of my knowledge and belief. If prepared by a person
other than an officer of the corporation, your declaration is based on all information of which you have knowledge.
SIGNATURE OF PREPARER
PRINTED NAME
TITLE
DATE
__ __ / __ __ / __ __ __ __
SIGNATURE OF OFFICER
PRINTED NAME
TITLE
DATE
__ __ / __ __ / __ __ __ __
Please return this questionnaire to: Missouri Department of Revenue, Taxation Division, P.O. Box 295, Jefferson City, MO 65105-0295
Additional space for explanations (continued on page 4). Please refer to questions by number.
MO 860-2629 (08-2010)
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