Form Mo W-4c - Withholding Affidavit For Missouri Residents printable pdf download

Form Mo W-4c - Withholding Affidavit For Missouri Residents

MISSOURI DEPARTMENT OF REVENUE

FORM

EMPLOYER: Retain this Form MO W-4C for

TAXATION DIVISION

MO W-4C

your records. The Department of Revenue may

WITHHOLDING AFFIDAVIT

request a copy for verification, if necessary.

FOR MISSOURI RESIDENTS

(REV. 08-2012)

THIS FORM IS TO BE COMPLETED BY A MISSOURI RESIDENT EMPLOYED IN A FOREIGN STATE.

I, the undersigned, hereby swear the following information is true and correct. I am a resident of the state of Missouri and an employee of

NAME OF EMPLOYER

EMPLOYER’S MISSOURI ID NUMBER

___ ___ ___ ___ ___ ___ ___ ___

ADDRESS

CITY, STATE, ZIP CODE

I realize that a Missouri resident is required to file an individual income tax return with the Missouri Department of Revenue by April 15 of

each year and report income from all sources. For withholding purposes however;

1. 100% of services for this employer are performed in the state of

, and income taxes are being

withheld by this employer for that state. I will attach to my Missouri individual income tax return, a copy of the return I file with that state.

Based on this sworn information, I hereby request no Missouri income tax be withheld from my wages.

2. _______ % of services for this employer are performed in the state of Missouri and are subject to Missouri withholding tax. Based on this

sworn information, I hereby request that Missouri tax be withheld on this pro rata share.

NAME

SOCIAL SECURITY NUMBER

___ ___ ___ - ___ ___ - ___ ___ ___ ___

ADDRESS

CITY, STATE, ZIP CODE

SIGNATURE

DATE

__ __ / __ __ / __ __ __ __

TDD 1-800-735-2966

MO W-4C (08-2012)

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Form Mo W-4c - Withholding Affidavit For Missouri Residents