Form 4096 - Authorization For Release Of Confidential Information
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MISSOURI DEPARTMENT OF REVENUE
FORM
WITHHOLDING TAX JOB TRAINING PROGRAM
4096
AUTHORIZATION FOR RELEASE OF
CONFIDENTIAL INFORMATION
(REV. 08-2012)
I,
, the undersigned principal, who is an officer authorized to sign for
the corporation, or is the owner of the business, identified by Missouri Tax Identification Number
and Federal Identification Number
–
, do hereby authorize and request the Depart-
ment of Revenue, State of Missouri, to release the confidential employer withholding tax records pertaining to the above specified
account for all tax reporting periods relating to participation in:
New Jobs Training Program
Job Retention Training Program.
This authorization shall be effective this date and until all of the costs associated with my Job Training Program have been paid in
full.
I, specifically authorize release of such information to the Department of Economic Development, Division of Workforce Develop-
ment.
I, hereby release the Director of Revenue and department personnel from any and all liability pursuant to unauthorized disclosures
of confidential tax information resulting from release of subject information under Section 32.057, RSMo, or any other applicable
confidentiality statute.
Under penalties of perjury, I declare that I have examined this authorization, and, to the best of my knowledge and belief, it is true,
correct, and complete. If prepared by a person other than the owner, this declaration is based on all information of which he has any
knowledge.
Under the penalties of perjury, I declare that I have the authority to make this request on behalf of ___________________________
_________________________________________ (business name).
OWNER/OFFICER SIGNATURE
DATE
PHONE NUMBER
__ __ / __ __ / __ __ __ __ (__ __ __) __ __ __ - __ __ __ __
TITLE
PLEASE SEND COMPLETED FORM TO:
Missouri Department of Revenue
P.O. Box 3375
Jefferson City, MO 65105-3375
DOR-4096 (08-2012)
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