MISSOURI DEPARTMENT OF REVENUE FORM REQUEST FOR TAX CLEARANCE FOR TRANSIENT EMPLOYERS Phone: (573) 751-0459 Fax: (573) 522-1722 943T (REV. 09-2010) PLEASE COMPLETE THIS FORM IN ITS ENTIRETY AND MAIL TO THE MISSOURI DEPARTMENT OF REVENUE, TAXATION DIVISION, P.O. BOX 357, JEFFERSON CITY, MO 65105-0357 TO OBTAIN A TAX CLEARANCE. MISSOURI TAX IDENTIFICATION OR EXEMPTION NUMBER __ __ __ __ __ __ __ __ FEDERAL EMPLOYER IDENTIFICATION NUMBER (FEIN) CHARTER NUMBER/CERTIFICATE OF AUTHORITY NUMBER __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ HOME STATE OF INCORPORATION BEGIN DATE DOING MISSOURI BUSINESS/CERTIFICATE OF AUTHORITY IN MISSOURI __ __ /__ __ /__ __ __ __ 1. Does this business have Missouri resident employees for which they are required to withhold Missouri taxes? YES NO 2. Does the business have non-resident employees working in Missouri? YES NO 3. Do you pay contributions to the Division of Employment Security? YES NO If yes, what is that account number? ______________ If there has been a change in the ownership of your business, you may need to contact the Taxation Division at (573) 751-0459 to ensure your account is properly registered. TYPE OF OWNERSHIP CORPORATION SOLE PROPRIETORSHIP PARTNERSHIP LIMITED LIABILITY COMPANY — How are you taxed? (check one) As a corporation As a sole owner As a partnership MAILING ADDRESS OF BUSINESS (NOTE: This is where the correspondence will be mailed, if the Authorization for Release of Confidential Information Section below is not completed.) NAME OF BUSINESS OR CORPORATION DOING BUSINESS AS NAME (DBA) BUSINESS MAILING ADDRESS CITY, STATE, ZIP CODE CONTACT PERSON CONTACT PHONE NUMBER ( __ __ __ ) __ __ __ - __ __ __ __ CORPORATIONS If there has been a name change for this corporation, please provide the prior name. _______________________________________________________________________________________________ This corporation files consolidated corporation income tax returns in Missouri. a. The parent corporation’s FEIN that these returns are being filed under is: ___ ___ ___ ___ ___ ___ ___ ___ ___ b. The Missouri Tax Identification Number of the parent corporation is: ___ ___ ___ ___ ___ ___ ___ ___ Missouri corporation franchise tax returns cannot be filed consolidated and must be filed by each corporation. SOLE PROPRIETORSHIPS YOUR SOCIAL SECURITY NUMBER SPOUSE’S SOCIAL SECURITY NUMBER __ __ __ - __ __ - __ __ __ __ __ __ __ - __ __ - __ __ __ __ If individual income tax returns have previously been filed in another state, please provide a list of the states and years filed. Authorization for Release of Confidential Information: All correspondence will be released to the person authorized below. Release of this information to a third party (such as an accountant) at the request of the taxpayer does not give the third party authority to request further information from the Department. To obtain additional information or to represent the taxpayer before the Department, the taxpayer must execute a Power of Attorney designating the third party as its representative. NAME OF PERSON AUTHORIZED TO RECEIVE THIS INFORMATION TITLE PHONE NUMBER (___)___-____ ADDRESS CITY, STATE, ZIP CODE SIGNATURE OF OWNER, PARTNER, OR CORPORATE OFFICER Under penalties of perjury I declare that the above information is true and complete. SIGNATURE OF OWNER/OFFICER TITLE PHONE NUMBER ( __ __ __ ) __ __ __ - __ __ __ __ PLEASE MAIL THE COMPLETED FORM TO: MISSOURI DEPARTMENT OF REVENUE, TAXATION DIVISION, P.O. BOX 357, JEFFERSON CITY, MO 65105-0357. MO 860-2785 (09-2010) This publication is available upon request in alternative accessible format(s). American LegalNet, Inc. www.FormsWorkFlow.com