Form 4854 - Employer Withholding Tax Refund Request

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MISSOURI DEPARTMENT OF REVENUE
PLEASE NOTE: You must receive
FORM
TAXATION DIVISION
confirmation from the Department of
4854
PO BOX 3375
Revenue that a valid overpayment
JEFFERSON CITY MO 65105-3375
(REV. 03-2010)
exists prior to completing this form.
EMPLOYER WITHHOLDING TAX REFUND REQUEST
MO TAX I.D. NUMBER:
TAX PERIOD (YYYYMM):
AMOUNT OF OVERPAY:
____ ____ ____ ____ ____ ____
FEDERAL I.D. NUMBER (FEIN):
TELEPHONE NUMBER:
DOR USE ONLY
BUSINESS NAME
BUSINESS ADDRESS
PROVIDE A DETAILED DESCRIPTION OF THE REASON FOR OVERPAYMENT. (REQUIRED)
SIGNATURE (REQUIRED)
DATE:
SEND COMPLETED FORM TO: MISSOURI DEPARTMENT OF REVENUE, P.O. BOX 3375, JEFFERSON CITY, MO 65105-3375
DOR-4854 (03-2010)
Reset Form
Print Form
MISSOURI DEPARTMENT OF REVENUE
PLEASE NOTE: You must receive
FORM
TAXATION DIVISION
confirmation from the Department of
4854
PO BOX 3375
Revenue that a valid overpayment
JEFFERSON CITY MO 65105-3375
exists prior to completing this form.
(REV. 03-2010)
EMPLOYER WITHHOLDING TAX REFUND REQUEST
MO TAX I.D. NUMBER:
TAX PERIOD (YYYYMM):
AMOUNT OF OVERPAY:
____ ____ ____ ____ ____ ____
FEDERAL I.D. NUMBER (FEIN):
TELEPHONE NUMBER:
DOR USE ONLY
BUSINESS NAME
BUSINESS ADDRESS
PROVIDE A DETAILED DESCRIPTION OF THE REASON FOR OVERPAYMENT. (REQUIRED)
SIGNATURE (REQUIRED)
DATE:
SEND COMPLETED FORM TO: MISSOURI DEPARTMENT OF REVENUE, P.O. BOX 3375, JEFFERSON CITY, MO 65105-3375
DOR-4854 (03-2010)

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