Form Mo W-4a - Certificate Of Nonresidence/ Allocation Of Withholding Tax

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MISSOURI DEPARTMENT OF REVENUE
FORM
TAXATION DIVISION
MO W-4A
CERTIFICATE OF NONRESIDENCE/
(REV. 01‑2012)
ALLOCATION OF WITHHOLDING TAX
This form is to be completed by a nonresident who performs a determinable percentage of services within Missouri.
NAME
SOCIAL SECURITY NUMBER
___ ___ ___ ‑ ___ ___ ‑ ___ ___ ___ ___
ADDRESS
CITY, STATE, ZIP CODE
EMPLOYEE: THIS FORM TO BE FILED WITH EMPLOYER — DO NOT SEND TO DEPARTMENT OF REVENUE
I hereby certify 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. 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.
SIGNATURE
DATE
__ __ / __ __ / __ __ __ __
EMPLOYER: For information on how this allocation may be determined, please refer to the Employer’s Tax Guide at
MO W‑4A (01‑2012)
TDD (800) 735‑2966

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