Form 4098 - Application For Direct Pay Authorization - 2015 Page 2
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1
2Street 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):
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):
To verify if the business is located inside the city limits of any city or municipality visit https://dors.mo.gov/tax/strgis/index.jsp.
Sales Tax Rule
12 CSR 10-104.040
provides in part that records must be submitted to demonstrate that the business or corporation annually
purchases non-resalable items in excess of $750,000.
32.057, RSMo,
Missouri Statute
states that all tax records and information maintained by the Missouri Department of Revenue are
confidential. The tax information can only be given to the owner, partner, member, or officer who is listed with us as such. If you wish
to give an employee, attorney, or accountant access to your tax information, you must supply us with a power of attorney giving us the
authority to release confidential information to them.
Under penalties of perjury, I declare that the above information and any attached supplement is true, complete, and correct. The application
must be signed by the owner, if the business is a sole ownership; partner, if the business is a partnership; reported officer, if the business is a
corporation or by a member, if the business is an L.L.C. as reported on this application.
Signature of Officer or Responsible Person
Title
Printed Name
E-mail Address
Social Security Number
Date of Birth (MM/DD/YYYY)
Date (MM/DD/YYYY)
___ ___ / ___ ___ / ___ ___ ___ ___
___ ___ / ___ ___ / ___ ___ ___ ___
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Form 4098 (Revised 08-2015)
Mail to:
Taxation Division
Phone: (573) 751-2836
Visit
P.O. Box 358
TTY: (800) 735-2966
for additional information.
Jefferson City, MO 65105-0358
Fax: (573) 522-1271
E-mail:
salestaxexemptions@dor.mo.gov
*14020020001*
14020020001
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Parent category: Business