Form 4098 - Application For Direct Pay Authorization - 2015

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Department Use Only
Missouri Department of Revenue
(MM/DD/YY)
Form
4098
Application For Direct Pay Authorization
Missouri Tax I.D.
Federal Employer
Number
I.D. Number
This application is to be used for applying for or renewing the direct pay authorization pursuant to
Section 144.190.6,
RSMo. This
authorization, if issued, is valid for five years.
New Application
Renewal
Type of application (select one):
r
r
Business Name (attach list if necessary for additional locations)
Physical Address (Do not use PO Box or Rural Route Number)
County
City
State
ZIP Code
Business Telephone Number
E-mail Address
( ___ ___ ___ ) - ___ ___ ___ - ___ ___ ___ ___
Mailing Address
City
State
ZIP Code
Owner Name (Enter Corporation or LLC Name, if applicable)
Address
County
City
State
ZIP Code
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
County
City
State
ZIP Code
Is this business located inside the city limits of any city or municipality in Missouri?
r
r
No
Yes - Specify the city:
Is this business located inside a district(s)? For example, ambulance, fire, tourism, community, or transportation development.
r
r
No
Yes - Specify the district name(s):
Street Address - Do Not Use PO Box or Rural Route
County
City
State
ZIP Code
Is this business located inside the city limits of any city or municipality in Missouri?
r
r
No
Yes - Specify the city:
Is this business located inside a district(s)? For example, ambulance, fire, tourism, community, or transportation development.
r
r
No
Yes - Specify the district name(s):
*14020010001*
14020010001
Form 4098 (Revised 08-2015)

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