Form 5143 - Safe At Home - Request For Address Confidentiality Of Tax Records
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MISSOURI DEPARTMENT OF REVENUE
TAXATION DIVISION
PO BOX 2200
FORM
JEFFERSON CITY MO 65105-2200
5143
SAFE AT HOME - REQUEST FOR ADDRESS
CONFIDENTIALITY OF TAX RECORDS
(REV. 08-2010)
This form must be completed and returned to the Missouri Department of Revenue, Taxation Division, to initiate/update
a “Safe at Home” address for taxes administered by the Taxation Division. To change any other addresses to a “Safe at
Home” address please contact the appropriate area or government agency.
Please complete the information below and attach a copy of your “Safe at Home” authorization card issued by the
Secretary of State. This information will be used to update your mail-to address in the Taxation Division’s records with your “Safe
at Home” address. Your “Safe at Home” address will be used only on the tax types you designate below.
INDIVIDUAL INCOME TAX
Taxpayer Name (last, first, middle)
Social Security Number
Previous Address
City
State
Zip
BUSINESS TAX
Business Name
Missouri Tax ID Number
Previous Address
City
State
Zip
Safe at Home Identification Number
_____ _____ _____ _____
TAX RECORDS
Check the box or boxes below for the tax programs that affect you.
Individual Income Tax
Sales Tax
Property Tax Credit
Vendor’s Use Tax
Fiduciary Tax
Consumer’s Use Tax
Employer Withholding Tax
Corporation Income Tax
Cigarette/Other Tobacco Products Tax
Corporation Franchise Tax
Motor Fuel Tax
Tire and/or Battery Fee
Other: (Please Specify) _______________________________
_______________________________
I understand the "Safe at Home" address will be used as my mailing address for the Department to send tax related mail for the taxes
noted above. This address only affects the mailing address of my residence and does not affect any other addresses. This
address will be used until I notify the Department of an address change or the Secretary of State rejects my mail because I am no longer
a qualified participant of the “Safe at Home” program. I understand if I file any returns or other documents or any are filed on my behalf,
with a non-“Safe at Home” address, it constitutes notification to the Taxation Division that I am no longer in the “Safe at Home”
program and the Taxation Division will no longer use the “Safe at Home” address as my mail-to address. I also confirm that I have been
certified as an authorized “Safe at Home” program participant approved by the Secretary of State.
Signature
Date
___ ___ /___ ___ /___ ___ ___ ___
Mail to:
Missouri Department of Revenue
Taxation Division
If you have any questions, please contact
P.O. Box 2200
the Taxation Division at (573) 751-3505.
Jefferson City, Missouri 65105
A copy of your “Safe at Home” authorization card must be attached with this form.
DOR-5143 (08-2010)
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