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MISSOURI DEPARTMENT OF REVENUE
TAXATION DIVISION
FORM
P.O. BOX 358
1746R
JEFFERSON CITY, MISSOURI 65105‑0358
(573) 751‑2836 FAX: (573) 751‑9409
(REV. 09-2012)
E‑mail: salestaxexemptions@dor.mo.gov
MISSOURI SALES OR USE TAX EXEMPTION RENEWAL APPLICATION
1. MISSOURI TAX ID NUMBER
2. FEDERAL ID NUMBER
ORGANIZATION NAME AND LOCATION
3. ORGANIZATION NAME
STREET ADDRESS — DO NOT USE P.O. BOX OR RURAL ROUTE
PHONE
(__ __ __) __ __ __ - __ __ __ __
CITY
STATE
ZIP CODE
COUNTY
DOES YOUR ORGANIZATION OWN PROPERTY IN MISSOURI?
WEB SITE ADDRESS
YES
NO
IS YOUR ORGANIZATION EXEMPT FROM PROPERTY TAX?
YES
NO
DATE ORGANIZATION ORIGINATED:
INCORPORATED ORGANIZATIONS
MISSOURI CHARTER NUMBER
DATE INCORPORATED (MM/DD/YYYY)
MISSOURI CORPORATION
__ __ __ __ __ __ __ __ __ __
_ _ / _ _ / _ _ _ _
MISSOURI CERTIFICATE OF AUTHORITY NO.
DATE REGISTERED IN MISSOURI (MM/DD/YYYY)
STATE OF INCORPORATION
OUT-OF-STATE CORPORATION
_ _ / _ _ / _ _ _ _
MAILING ADDRESS
4. MAILING ADDRESS (IF DIFFERENT THAN ORGANIZATION ADDRESS)
STREET ADDRESS OR P.O. BOX
CITY
STATE
ZIP CODE
COUNTY
__ __ __ __ __
ORGANIZATION OR AGENCY OFFICERS
5. NAME (LAST, FIRST, MIDDLE INITIAL)
TITLE
SOCIAL SECURITY NUMBER
BIRTHDATE (MM/DD/YYYY)
__ _ _ / _ _ / _ _ _ _
__ __ __ - __ __ - __ __ __
STREET ADDRESS
CITY
STATE
ZIP CODE
__ __ __ __ __
NAME (LAST, FIRST, MIDDLE INITIAL)
TITLE
SOCIAL SECURITY NUMBER
BIRTHDATE (MM/DD/YYYY)
__
_ _ / _ _ / _ _ _ _
__ __ __ - __ __ - __ __ __
STREET ADDRESS
CITY
STATE
ZIP CODE
__ __ __ __ __
ATTACHMENTS
ATTACH a complete financial history for the last three years (or number of years in existence if less than three) indicating sources and amounts of
income and a breakdown of expenditures.
Provide a written description of civic or charitable activities. Please be specific and provide examples.
SIGNATURE
6. 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 and 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 organiza-
tion 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.
• That I employ no illegal or unauthorized aliens as defined under federal law and that I am not eligible for any tax.
PRINT NAME
E-MAIL ADDRESS
SIGNATURE OF OFFICER OR RESPONSIBLE PERSON
TITLE
DATE (MM/DD/YYYY)
_ _ / _ _ / _ _ _ _
CONFIDENTIALITY OF TAX RECORDS
Missouri Statute 32.057, RSMo, states that all tax records and information maintained by the Missouri Department of Revenue are confidential. The tax
information can only be given to the owner, partner, member, or officer who is listed with us as such. If you wish to give an employee, attorney, or accountant
access to your tax information, you must supply us with a power of attorney giving us the authority to release confidential information to them.
For more information, visit
DOR-1746R (09-2012)