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MISSOURI DEPARTMENT OF REVENUE
TAXATION DIVISION
FORM
P.O. BOX 358, JEFFERSON CITY, MISSOURI 65105-0358
4098
APPLICATION FOR DIRECT PAY
AUTHORIZATION
(REV. 7-2012)
(573) 751-2836 FAX: (573) 751-9409
E-mail: salestaxesemptions@dor.mo.gov
This application is to be used for applying for or renewing the direct pay authorization pursuant to Section 144.190.4, RSMo. This
authorization, if issued, is valid for five (5) years.
1.
MISSOURI TAX ID NUMBER
FEIN
NEW APPLICATION
RENEWAL
2.
BUSINESS NAME AND PHYSICAL LOCATION
Business Name (attach list if necessary for additional locations)
Street, Highway (Do not use PO Box or Rural Route Number)
City, State, Zip Code
County
Business Telephone Number
(__ __ __) __ __ __ - __ __ __ __
3.
OWNER NAME AND ADDRESS
Owner Name (Enter Corporation or LLC Name, if applicable)
Address
City
State
Zip Code
County
4.
BUSINESS MAILING ADDRESS
Street, Route or PO Box Number
City
State
Zip Code
5.
LIST BUSINESS LOCATIONS FOR WHICH YOU ARE REQUESTING DIRECT PAY AUTHORIZATION (ATTACH A
SUPPLEMENTAL LIST IF NECESSARY).
STREET ADDRESS - DO NOT USE PO BOX OR RURAL ROUTE
CITY
STATE
ZIP CODE
COUNTY
Is this business located inside the city limits of any city or municipality in Missouri? To verify go to https://dors.mo.gov/tax/strgis/index.jsp
No
Yes - Specify the city:
Is this business located inside a district(s)? For example, ambulance, fire, tourism, community or transportation development.
No
Yes - Specify the district name(s):
STREET ADDRESS - DO NOT USE PO BOX OR RURAL ROUTE
CITY
STATE
ZIP CODE
COUNTY
Is this business located inside the city limits of any city or municipality in Missouri? To verify go to https://dors.mo.gov/tax/strgis/index.jsp
No
Yes - Specify the city:
Is this business located inside a district(s)? For example, ambulance, fire, tourism, community or transportation development.
No
Yes - Specify the district name(s):
This publication is available upon request in alternative accessible format(s). TDD (800) 735-2966
MO 860-2350 (07-2012)
DOR 4098 (07-2012)