Form 126 - Registration Or Exemption Change Request - 2016 Page 2
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All information is required if completing the Authorized Representatives Section. Attach a list if needed.
Business Tax Accounts: Identify all persons who are not a partner, member (L.L.C), or officer of the business that have direct supervision or
control over tax matters whom you authorize the Department to discuss your tax matters. All other persons must obtain a Missouri Power of
Attorney (Form 2827). Attach a list if needed.
Title Begin or End Date (MM/DD/YYYY) Name (Last, First, Middle Initial)
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Add
Remove
__ __ / __ __ / __ __ __ __
Title
Social Security Number
Birthdate (MM/DD/YYYY)
__ __ / __ __ / __ __ __ __
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Home Address
City
State
Zip Code
County
Title Begin or End Date (MM/DD/YYYY) Name (Last, First, Middle Initial)
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Add
Remove
__ __ / __ __ / __ __ __ __
Title
Social Security Number
Birthdate (MM/DD/YYYY)
__ __ / __ __ / __ __ __ __
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Home Address
City
State
Zip Code
County
Title Begin or End Date (MM/DD/YYYY) Name (Last, First, Middle Initial)
r
r
Add
Remove
__ __ / __ __ / __ __ __ __
Title
Social Security Number
Birthdate (MM/DD/YYYY)
__ __ / __ __ / __ __ __ __
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Home Address
City
State
Zip Code
County
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All Tax Types
Corporate Income and Franchise Tax
Employer Withholding Tax
Sales and Use Tax
Change For:
In Care Of (Optional)
Company Name if different from owner
Address
City
State
Zip Code
County
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Consumer’s Use Tax
Employer Withholding Tax
Sales Tax
Vendor’s Use Tax
Close the following business location for:
Business Name
Address
City
State
Zip Code
County
Date of Closing (MM/DD/YYYY)
__ __ / __ __ / __ __ __ __
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Employer Withholding Tax
Open the following new business location for:
Consumer’s Use Tax
Sales Tax
Vendor’s Use Tax
Business Name
Taxable Sales Begin Date (MM/DD/YYYY
___ ___ / ___ ___ / ___ ___ ___ ___
Street or Highway Address (Do not use Rural Route or PO Box)
City
State
Zip Code
County
*15600020001*
15600020001
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Parent category: Financial