Form 4854 - Employer Withholding Tax Refund Request - Missouri Department Of Revenue

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Department Use Only
Missouri Department of Revenue
(MM/DD/YY)
Form
4854
Employer Withholding Tax Refund Request
Reporting Period
(MM/YY)
Missouri Tax I.D.
Federal Employer
Number
I.D. Number
Please logon to the Online Credit Inquiry System to verify all overpayments on your account prior to completing this form.
Business Name
Overpay Amount
Business Address
Telephone Number
(__ __ __) __ __ __ - __ __ __ __
City
State
Zip Code
Tax Year __________
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January
February
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Tax Year __________
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January
February
March
April
May
June
July
August
September
October
November
December
Tax Year __________
r
r
r
r
r
r
r
r
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r
January
February
March
April
May
June
July
August
September
October
November
December
Tax Year __________
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January
February
March
April
May
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July
August
September
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November
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Provide a detailed description of the reason for overpayment. (Required)
Signature (Required)
Date (MM/DD/YYYY)
___ ___ / ___ ___ / ___ ___ ___ ___
Form 4854 (Revised 12-2014)
Mail to:
Taxation Division
Phone: (573) 751-7200
Visit
P.O. Box 3375
Fax: (573) 522-6816
for additional information.
Jefferson City, MO 65105-3375
E-mail:
withholding@dor.mo.gov
*1421001001*
14210010001

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