Form 8821 - Authorization For Release Of Confidential Information - Missouri Department Of Revenue
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Missouri Department of Revenue
Department Use Only
Authorization For Release of
Form
(MM/DD/YY)
8821
Confidential Information
Missouri Tax I.D.
Social Security
Number
Number
I,
, authorize and request the Missouri Department of Revenue, to release confidential tax
records pertaining to
for the tax reporting period(s):
.
r
r
Corporate Income and Franchise Tax
Sales or Use Tax
r
r
Employer Withholding Tax
Motor Fuel Tax
r
r
Individual Income Tax
Financial Institution Tax
(List Social Security Number under Missouri Tax ID Number)
r
Other _________________________________________________________________________________________
The record should be:
r
Photocopied and copies forwarded to me at: Street: ____________________________________________________
City, State, Zip: ____________________________________________________
r
Photocopied and copies forwarded to the agent specified below.
I specifically authorize the following agent to examine the above identified confidential tax records.
Name
Title
Social Security Number
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Street Address
City
State
Zip Code
Telephone Number
E-mail Address
(
)
-
___ ___ ___
___ ___ ___
___ ___ ___ ___
(Complete this section if requesting confidential tax records for a business, corporation, s corporation, or partnership)
I am authorized to sign this document as an officer, partner, or owner of the corporation or business. This authorization shall
be effective this date and shall expire on __________________________________________, or until terminated by the undersigned.
For sales tax records only — The Director of Revenue may charge not more than $50 per day for use of facilities within the division or
charge not more than one dollar per page for photocopies of confidential records to defray costs incurred.
Under penalties of perjury, I declare that the above information and any attached supplement is true, complete, and correct. If prepared by
a person other than the owner, this declaration is based on all information of which he or she has any knowledge. The Director of Revenue
and department personnel, are hereby released from any and all liability pursuant to unauthorized disclosures of confidential tax information
resulting from release of information under
Section 32.057, RSMo
or any other applicable confidentiality statute.
Signature of Owner, Officer, Partner, or Individual
Date (MM/DD/YYYY)
Telephone Number
(
)
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__ __ /__ __ /__ __ __ __
___ ___ ___
___ ___ ___
___ ___ ___ ___
Printed Name
Title
Social Security Number
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Form 8821 (Revised 12-2014)
Send Completed Form To (Tax type selected above will determine appropriate mailing address):
Corporate Income and Franchise Tax
Individual Income Tax
All Other Taxes
Business Tax
Personal Tax
Support Services
P.O. Box 3365
P.O. Box 2200
P.O. Box 3022
Jefferson City, MO 65105-3365
Jefferson City, MO 65105-2200
Jefferson City, MO 65105-3022
14311010001
14311010001
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