Fillable Form 943t - Request For Tax Clearance For Transient Employers

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MISSOURI DEPARTMENT OF REVENUE

FORM

REQUEST FOR TAX CLEARANCE FOR

943T

TRANSIENT EMPLOYERS

(REV. 01-2012)

Phone: (573) 751-0459

Fax: (573) 522-1722

PLEASE COMPLETE THIS FORM IN ITS ENTIRETY AND MAIL TO THE MISSOURI DEPARTMENT OF REVENUE, TAXATION DIVISION,

P.O. BOX 357, JEFFERSON CITY, MO 65105-0357 TO OBTAIN A TAX CLEARANCE.

MISSOURI TAX IDENTIFICATION OR EXEMPTION NUMBER

FEDERAL EMPLOYER IDENTIFICATION NUMBER (FEIN)

CHARTER NUMBER/CERTIFICATE OF AUTHORITY NUMBER

__ __ __ __ __ __ __ __

__ __ __ __ __ __ __ __ __

__ __ __ __ __ __ __ __ __ __

HOME STATE OF INCORPORATION

BEGIN DATE DOING MISSOURI BUSINESS/CERTIFICATE OF AUTHORITY IN MISSOURI

__ __ /__ __ /__ __ __ __

1. Does this business have Missouri resident employees for which they are required to withhold Missouri taxes?

YES

2. Does the business have non-resident employees working in Missouri?

YES

3. Do you pay contributions to the Division of Employment Security?

YES

NO If yes, what is that account number? ______________

If there has been a change in the ownership of your business, you may need to contact the Taxation Division at

TYPE OF OWNERSHIP

(573) 751-0459 to ensure your account is properly registered.

LIMITED LIABILITY COMPANY — How are you taxed? (check one)

CORPORATION

SOLE PROPRIETORSHIP

PARTNERSHIP

As a corporation

As a sole owner

As a partnership

MAILING ADDRESS OF BUSINESS

(NOTE: This is where the correspondence will be mailed, if the Authorization for Release of Confidential Information Section below is not completed.)

NAME OF BUSINESS OR CORPORATION

DOING BUSINESS AS NAME (DBA)

BUSINESS MAILING ADDRESS

CITY, STATE, ZIP CODE

CONTACT PERSON

CONTACT PHONE NUMBER

( __ __ __ ) __ __ __ - __ __ __ __

If there has been a name change for this corporation, please provide the prior name.

CORPORATIONS

_______________________________________________________________________________________________

This corporation files consolidated corporation income tax returns in Missouri.

a. The parent corporation’s FEIN that these returns are being filed under is: ___ ___ ___ ___ ___ ___ ___ ___ ___

b. The Missouri Tax Identification Number of the parent corporation is: ___ ___ ___ ___ ___ ___ ___ ___

Missouri corporation franchise tax returns cannot be filed consolidated and must be filed by each corporation.

YOUR SOCIAL SECURITY NUMBER

SPOUSE’S SOCIAL SECURITY NUMBER

SOLE PROPRIETORSHIPS

__ __ __ - __ __ - __ __ __ __

If individual income tax returns have previously been filed in another state, please provide a list of the states and years filed.

Authorization for Release of Confidential Information: All correspondence will be released to the person authorized below. Release of this

information to a third party (such as an accountant) at the request of the taxpayer does not give the third party authority to request further information

from the Department. To obtain additional information or to represent the taxpayer before the Department, the taxpayer must execute a Power of Attorney

designating the third party as its representative

NAME OF PERSON AUTHORIZED TO RECEIVE THIS INFORMATION

TITLE

PHONE NUMBER

( _ _ _ ) _ _ _ - _ _ _ _

ADDRESS

CITY, STATE, ZIP CODE

SIGNATURE OF OWNER, PARTNER, OR CORPORATE OFFICER

Under penalties of perjury I declare that the above information is true and complete.

SIGNATURE OF OWNER/OFFICER

TITLE

PHONE NUMBER