Statement Of Tax Responsibility - University Of Missouri System

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Statement of Tax Responsibility
I, _______________________, a resident of __________________ (state of residence)
am formally requesting the University of Missouri to not withhold Missouri income taxes
from my pay due to the fact that I am performing services for the University outside of
Missouri, or I am a retiree residing outside of Missouri. Please make this form effective
as of __________(Note any date prior the beginning of the current year would require
corrected forms and the associated fees). In doing so, I realize that I accept full
responsibility for paying income taxes to my state of residence by means required of said
state, (e.g., by filing Estimated Income Tax returns or other means that may be required
by the state). This request will continue until a new form is submitted for a change in my
state of residence, and/or until a new form is submitted for a change in my state of work
location. If I shall become a resident of Missouri, I will fill out a Missouri W-4 form to
initiate Missouri taxes and/or if my work location changes to Missouri, I will fill out a
Missouri W-4 form to initiate Missouri taxes.
_____________________
(Signature)
_____________________
(EmplID)
_____________________
(Date)

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