Form Mo-Tf - Missouri Tax Credit Transfer Form - 2014 Page 2
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Federal Employer I.D. Number (FEIN)
Missouri Tax I.D. Number
Social Security Number
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Contact Person
Title
Address
City
State
ZIP Code
Telephone Number
Fax Number
E-mail
(___ ___ ___)___ ___ ___-___ ___ ___ ___
(___ ___ ___)___ ___ ___-___ ___ ___ ___
Select One
r
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r
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r
C Corporation
Financial Institution
Individual
Individual Filing a Joint Return
Limited Liability Company (LLC)
r
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S Corporation
Partnership
Sole Proprietor
Other __________________________________________________
If the taxpayer is an individual filing a joint return, list the primary and secondary names and social security numbers below.
If the taxpayer is a Partnership, S Corporation, or other entity with a flow through tax treatment, identify the names, social
security numbers, and proportionate share of ownership of each beneficiary, partner, or shareholder on the last day of the tax
period. Aggregate proportionate shares or percent of total ownership must be less than 100%. Attach a separate sheet if necessary.
Federal Employer I.D. Number, Missouri Tax
Name(s)
% Ownership Year End
I.D. Number, or Social Security Number
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%
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%
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%
Under penalties of perjury, I declare that the above information and any attached supplement is true, complete, and correct. I certify that I am an
authorized representative of the Assignee and as such am authorized to make the statement of affirmation contained herein.
Assignee Signature
Title
Print Name
Date (MM/DD/YYYY)
___ ___ / ___ ___ / ___ ___ ___ ___
Subscribed and sworn before me, this
Embosser or black ink rubber stamp seal
day of
year
State
County (or City of St. Louis)
My Commission Expires (MM/DD/YYYY)
__ __ /__ __ /__ __ __ __
Notary Public Signature
Notary Public Name (Typed or Printed)
*14305020001*
14305020001
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