Form Mo-3nr - Partnership/s Corporation Withholding Exemption/ Revocation Agreement

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MISSOURI DEPARTMENT OF REVENUE
DLN
FORM
PARTNERSHIP/S CORPORATION
MO-3NR
WITHHOLDING EXEMPTION/
REVOCATION AGREEMENT
(REV. 10-2010)
FOR CALENDAR YEAR JAN. 1 – DEC. 31,
, OR FISCAL YEAR BEGINNING
,
AND ENDING
,
PM
REVOCATION
DOR
INDICATOR
ONLY
PART 1 — NAME AND ADDRESS
BUSINESS NAME
FEDERAL I.D. NUMBER
NUMBER AND STREET
MITS/MISSOURI I.D. NUMBER
CITY OR TOWN, STATE, ZIP CODE
PARTNERSHIP
S CORPORATION
PART 2 — WITHHOLDING TAX EXEMPTION
TAXPAYER NAME
SOCIAL SECURITY NUMBER
STREET ADDRESS, CITY, STATE, AND ZIP CODE
I, _______________________________________, as a partner/shareholder of the above named partnership/S corporation,
request to be exempt from Missouri income tax withholding on my Missouri distributive share item(s) received through this
partnership/S corporation for the tax year ___________, and all subsequent tax years, until I notify the Department of a change in
this election. By signing this agreement, I agree to:
1) File an individual income tax return in accordance with the provisions of Section 143.481, RSMo, and make timely
payment of all taxes imposed on me by this state with respect to the income of the partnership/S corporation for
every year in which I maintain my exemption status; and
2) Be subject to personal jurisdiction in this state for the purpose of the collection of income taxes, together with related
interest and penalties, imposed on me by this state with respect to my distributive share of the income for this
partnership/S corporation.
PART 3 — WITHHOLDING TAX EXEMPTION REVOCATION
TAXPAYER NAME
SOCIAL SECURITY NUMBER
STREET ADDRESS, CITY, STATE AND ZIP CODE
I, __________________________________________, as a partner/shareholder of the above named partnership/S corporation, do
hereby revoke my previous withholding election dated ____ / ____/ _______. At this time, I request to be subject to withholding
by this partnership/S corporation on my Missouri distributive share item(s) received through this partnership/S corporation for tax
year ________, and all subsequent tax years, until I notify the Department of a change of this election.
PART 4 — PLEASE SIGN YOUR AGREEMENT
SIGNATURE OF TAXPAYER
DATE
DAYTIME TELEPHONE
DOR USE ONLY
_ _ / _ _ / _ _ _ _ (_ _ _) _ _ _ - _ _ _ _
MO 860-2764 (10-2010)

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