Form 4458 - Business Activity Questionnaire - 2016
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Department Use Only
Missouri Department of Revenue
Form
(MM/DD/YY)
4458
Business Activity Questionnaire
Missouri Tax I.D.
Federal Employer
Number
I.D. Number
Charter
Number
Name of Business
E-mail
Mailing Address
City
State
Zip Code
Business Telephone Number
Ownership Type
Date of Incorporation
State of Primary Business Location
/
/
( ___ ___ ___ ) ___ ___ ___ - ___ ___ ___ ___
___ ___
___ ___
___ ___ ___ ___
State of Incorporation
Nature of Business Activity in Missouri
Date Activity Began in Missouri
/
/
___ ___
___ ___
___ ___ ___ ___
Other States that the Company Conducts Business in
For the purpose of this questionnaire, “representative” includes employees, agents, independent contractors, brokers, others acting on your behalf, and any
other person residing in this state who directly or indirectly refers potential customers to you for a commission or other form of consideration by any means,
including, but not limited to, linking your business to the person’s internet website, making in-person oral presentations, or engaging in telemarketing.
1. Amount of gross receipts from the sale of tangible or intangible personal property or services during the last five years:
Year
From Points in Missouri
From Points in Missouri to
From Points outside Missouri
Ended
to points in Missouri
points outside Missouri
to points in Missouri
20__ __
$
$
$
20__ __
$
$
$
20__ __
$
$
$
20__ __
$
$
$
20__ __
$
$
$
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2. How are sales made in Missouri?
Internet
Representative
Telephone
Other:
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3. How are deliveries made into Missouri?
By common carrier
By your vehicles
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If by your vehicles, indicate if such vehicles are:
Owned
Leased
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Are the vehicles used to back-haul items from Missouri after delivery? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
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4. Have returns been filed with Missouri for any prior years by your business or any affiliated entity using its present name or another name?
Yes
No
If yes, what name(s) and Missouri Identification Number(s) ______________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
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5. Is your business the survivor of a merger, sale of assets, partial or complete liquidation or other dissolution of a business in Missouri? .
Yes
No
6. Does your business or any affiliated entity currently have, or has it had at any time, in Missouri an:
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Office
Agent
Warehouse
Place of Distribution
Sample or Sample Room/Place
Other place of busniess
If yes, please provide the following information for each place (use additional sheets if necessary):
a) Location: ___________________________________________________________________________________________________________
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b) Approximate beginning date and end date (if applicable) of operation: __ __ /__ __ /__ __ __ __ - __ __ /__ __ /__ __ __ __
N/A
Begin Date (MM/DD/YYYY)
End Date (MM/DD/YYYY)
*14308010001*
14308010001
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Parent category: Financial