Form Mo W-4a - Certificate Of Nonresidence Or Allocation Of Withholding Tax - 2013
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Missouri Department of Revenue
Certificate of Nonresidence or
Form
Allocation of Withholding Tax
MO W-4A
This form is to be completed by a nonresident who performs a determinable percentage of services within Missouri.
Employer: For information on how this allocation may be determined, please refer to the website listed below.
Employee: This form is to be filed with your employer. Do not send it to the Department of Revenue.
Name of Employee
Social Security Number
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Street Address
City
State
Zip Code
I estimate the proportion of services performed within Missouri and subject to the withholding tax to be __________%.
I will notify my employer within 10 days of any substantial change in proportion, or a change in status to resident of Missouri.
Under penalties of perjury, I declare that the above information and any attached supplement is true, complete, and correct. I also declare that I
am a nonresident of the State of Missouri, and reside at the address stated above and perform services partly within and partly without Missouri.
Signature
Title
Printed Name
Date (MM/DD/YYYY)
__ __ /__ __ /__ __ __ __
Form MO W-4A (Revised 11-2013)
Phone: (573) 751-8750
Taxation Division
TDD: (800) 735-2966
P.O. Box 999
Visit
Jefferson City, MO 65108-0999
Fax: (573) 522-6816
for additional information.
E-mail:
withholding@dor.mo.gov
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