Form Mo W-4c - Withholding Affidavit For Missouri Residents
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1— PLEASE TRIM ON THE DOTTED LINE PRIOR TO FILING —
MISSOURI DEPARTMENT OF REVENUE
EMPLOYER: Retain for your records and mail a copy to:
FORM
TAX ADMINISTRATION BUREAU
MISSOURI DEPARTMENT OF REVENUE
MO W-4C
TAX ADMINISTRATION BUREAU
WITHHOLDING AFFIDAVIT
P.O. BOX 2200
FOR MISSOURI RESIDENTS
(REV. 8-94)
JEFFERSON CITY, MISSOURI 65105-2200
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
Services of 50% or more for this employer are performed in the State of
, and I pay income tax to the
State of
on that income. I am entitled to a credit for taxes paid to that State when filing my Missouri return.
Services of
% (if any) for this employer are performed in the state of Missouri and are subject to Missouri withholding
tax on that portion.
I realize that a Missouri resident is required to file a return with the Missouri Department of Revenue by April 15 of each year and report his
income from all sources.
I will attach to my MO-1040 income tax return, a copy of the return I file in the foreign State.
Based on the above sworn information, I hereby request that no Missouri income tax be withheld from my wages earned in the
State of
.
NAME
SOCIAL SECURITY NUMBER
SPOUSE’S NAME
SOCIAL SECURITY NUMBER
ADDRESS
CITY, STATE, ZIP CODE
SIGNATURE
DATE
This publication is available upon request in alternative accessible format(s). TDD 1-800-735-2966
MO 860-0515 (8-94)
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