Fillable 2643 Form 2643 - Missouri Tax Registration Application

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2643 Form 2643 - Missouri Tax Registration Application

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What’s Inside . . .
Detailed Instructions .........................................................................................Pages 1 and 2
Form 2643, Missouri Tax Registration Application ............................................... Pages 3 – 6
Bond Instructions ..........................................................................................................Page 7
Business Buyer Beware ................................................................................................ Page ii
Acceptable Bond Types ................................................................................................Page 7
Checklist for Completing Application
- Social security number, address, and birthdate of each owner, officer, partner, or member.
- Physical address and mailing address for your business.
- Federal Employer Identification Number (FEIN) for your business. Visit www.irs.gov or call 1-800-829-4933
-
Sales or use tax—You will need to know your estimated monthly sales so we can determine your filing frequency.
- Withholding tax—You will need to know your estimated monthly wages paid, so we can determine your withholding filing
frequency.
-
Corporation or limited liability company—You should have your charter number or certificate of authority number from the
Missouri Secretary of State. (Most corporations and limited liability companies are required to obtain a charter number or
certificate of authority number to operate in Missouri.)
-
If the business has a previous owner, you will need to know the previous owner’s name and address. If possible, please
provide the previous owner’s tax identification number and the purchase price.
-
Power of Attorney (Form 2827) —If you would like to allow someone other than the listed owner(s) to sign the application
or handle tax matters with the Department of Revenue (Department), a Power of Attorney (Form 2827) must be completed
and signed by the appointee and a listed owner or member or officer and submitted to the Department with this application.
(Visit our website at http://dor.mo.gov/forms/ to obtain Power of Attorney (Form 2827).
Mail the application and bond to: Missouri Department of Revenue, P.O. Box 357, Jefferson City, MO 65105-0357 or call
(573) 751-5860 for assistance (TTY (800) 735-2966).
If you have questions relating to specific tax types, please refer to the following e-mail address:
Corporate Income Tax .......................... corporate@dor.mo.gov
Sales or Use Tax .................................. salesuse@dor.mo.gov
Withholding Tax .................................... withholding@dor.mo.gov
Business Tax Registration .................... businesstaxregister@dor.mo.gov
Form 2643 (Revised 04-2019)
Missouri Tax Registration Application
You can also complete your registration online by visiting our website at
http://dor.mo.gov/registerbusiness/
For sales, use and withholding tax facts, sales tax rates, and FAQs,
visit our website at http://dor.mo.gov/business/.
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Business Buyer Beware
Whose unpaid taxes will you be paying?
Find out the facts!!!
You may be liable as a successor!
• Every person purchasing a business or stock of goods immediately shall notify the Director of Revenue of the
business name, owner’s name, date of purchase, and type of business or stock of goods.
• All successors or purchasers shall withhold a sufficient amount of the purchase money to cover taxes, interest, or
penalties due and unpaid by all former owners or predecessors, whether immediate or not, until the former owners
or predecessors produce a receipt from the Director of Revenue showing that they have been paid or a certificate
stating that no taxes are due; otherwise, the successor or purchaser shall become personally liable for the unpaid
tax, penalty, and interest accrued.
Example: Mr. Smith purchases a business from Mr. Jones for $50,000. He acquires all the inventory. He does not
ask Mr. Jones for a Certificate of No Tax Due. Mr. Smith comes in to apply for a Missouri Tax I.D. Number and
receives it. However, because Mr. Smith did not obtain a Certificate of No Tax Due from Mr. Jones, after receiving his
license for the business he finds Mr. Jones has sales tax delinquencies totaling $20,000, which he must pay because
he is now successor. Mr. Smith is now paying two people for the business — Mr. Jones and the Department.
• All purchasers have a duty to discover whether taxes are due and unpaid by any former owner or predecessors,
whether immediate or not, and a lack of knowledge about successorship will not relieve a purchaser from successor
tax liability. Reliance on an affidavit pursuant to Missouri’s Bulk Transfer Act stating there were no creditors of the
business will not relieve a purchaser from successor tax liability.
Some questions you may want to ask yourself when purchasing a business:
1) Are you purchasing the building (real estate)?
2) Are you purchasing the inventory?
3) Are you purchasing the equipment?
4) Are you purchasing the fixtures?
If you answer “yes” to any of the above questions, please obtain a Certificate of No Tax Due for sales tax (or a Tax
Clearance if the seller had employer withholding tax or other tax types) from the seller before you purchase the
business.
If you have any questions concerning successorship, please call (573) 751-2836 or write the Department of Revenue,
Business Tax, P.O. Box 3390, Jefferson City, MO 65105-3390.
The Federal Privacy Act requires the Missouri Department of
Revenue (Department) to inform taxpayers of the Department’s
legal authority for requesting identifying information, including
social security numbers, and to explain why the information is
needed and how the information will be used.
Chapter 143 of the Missouri Revised Statutes authorizes the
Department of Revenue to request information necessary to carry
out the tax laws of the state of Missouri. Federal law 42 U.S.C.
Section 405 (c)(2)(C) authorizes the states to require taxpayers to
provide social security numbers.
The Department uses your social security number to identify you
and process your tax returns and other documents, to determine
and collect the correct amount of tax, to ensure you are complying
with the tax laws, and exchange tax information with the Internal
Revenue Service, other states, and the Multistate Tax Commission
(Chapter 32 and 143, RSMo). In addition, statutorily provided
non-tax uses are: (1) to provide information to the Department of
Higher Education with respect to applicants for financial assistance
under Chapter 173, RSMo; and (2) to offset refunds against amounts
due to a state agency by a person or entity (Chapter 143, RSMo).
Information furnished to other agencies or persons shall be used
solely for the purpose of administering tax laws or the specific laws
administered by the person having the statutory right to obtain it
as indicated above. (For the Department of Revenue’s authority
to prescribe forms and to require furnishing of social security
numbers, see Chapters 135, 143, and 144, RSMo.)
You are required to provide your social security number on your tax
return. Failure to provide your social security number, or providing
a false social security number, may result in criminal action against
you.
Federal Privacy Notice
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Instructions
Please review the instructions below before completing the application and if you have any questions,
contact Business Tax Registration.
1. Missouri Tax I.D. Number: If you have ever been issued a Missouri Tax I.D. Number by the Missouri Department of Revenue, enter it here.
If you do not have one, leave this field blank.
2. You may be required to submit a Federal Employer Iden ti fi ca tion Number (FEIN) to complete your business registration. The FEIN is issued
by the Internal Revenue Service (IRS). The FEIN is used to identify taxpayers that are required to file various business tax returns. Em ployers,
corporations, partnerships, limited liability companies, trusts and estates, and other business entities are required to have a FEIN. For more
information regarding FEINs or to obtain a number online, please contact the IRS at (800) 829-4933 or visit their website at www.irs.gov.
5. Ownership Type: Check the appropriate ownership type for your business. Be sure to include your charter number, certificate of
authority number, limited partnership number, limited liability partnership number, or limited liability number issued by the Secretary of State.
If you are a non-Missouri corporation, in clude the state of incorporation and date issued.
6. Previous Owner: If a business was previously operated at this location or you purchased any portion of the business from a previous owner,
You must complete this section. Protect yourself by obtaining a copy of a “No Tax Due” statement from the previous owner of the
business. The Department only issues this statement if requested by the previous owner and all sales or use taxes are paid in full. See page
ii for Business Buyer Beware.
7. Business Mailing Address: The Department mails reporting forms as well as confidential and non-confidential correspondence to the business
address listed on #4. If you want us to direct your mail to an address other than the business address for any of your taxes, enter that
address here and check the appropriate boxes. If this address is for a different company, please indicate that companies name.
9. Officers, Partners, and Mem bers: Identify all officers, partners, and members of your business who are responsible for the collection and
remittance of tax. If you are a sole owner and you completed the “Owner Information” on #19, you do not have to complete this section. If the
business is a partnership or limited liability partnership, enter all partners. If it is a limited partnership, include only the general partners.
If the business is owned by another corporation or LLC, please include that entity in the list of officers or members including the FEIN of that
corporation or LLC. Complete all information for each officer, partner, and member, including social security number and date of birth. Your
registration will not be complete unless we receive all requested information. Attach a list of officers, partners, and members if you cannot fit
them all on this page.
10. Authorized Representatives: Identify all persons who are not a partner, member (L.L.C), or officer of the business that have direct
supervision or control over tax matters whom you authorize the Department to discuss your tax matters. All other persons must obtain
a Missouri Power of Attorney (Form 2827). Complete all information for authorized representative(s), including social security number
and date of birth. Your registration will not be complete unless we receive all requested information. Attach a list if needed.
11-14. Sales or Use Tax: Complete this section if you are going to make retail sales subject to sales, vendor’s use, or consumer’s use tax.
Consumer’s Use Tax: Unlike sales tax, which requires a sale at retail in Missouri, use tax is imposed directly upon the person who stores,
uses, or consumes tangible personal property in Missouri. Use tax does not apply if the purchase is from a Missouri retailer and
subject to Missouri sales tax. A seller not engaged in business is not required to collect Missouri tax but the purchaser in these
instances is responsible for remitting use tax to Missouri. If an out-of-state seller does not collect use tax from the purchaser, the
purchaser is responsible for remitting the use tax to Missouri. A purchaser is required to file a use tax return if the cumulative purchases
subject to use tax exceed $2,000 in a calendar year.
Vendor’s Use Tax: If an out-of-state vendor makes sales of goods to a final consumer located in Missouri and the vendor has sufficient
nexus with Missouri, the vendor is required to collect and remit Missouri vendor’s use tax. The vendor is required to obtain a Missouri Use
Tax License and post a bond.
11. Retail Sales Tax License cannot be issued without a taxable begin date. If you are a seasonal business, check the months in which you
will make sales. We will only require you to file a return in the months you check.
14. Filing Frequency: Your filing fre quency is determined by the amount of state sales tax due. Multiply your anticipated month ly taxable sales
by 4 percent to arrive at your estimated monthly liability.
15. Business Name and Phys i cal Location: Enter all information regarding the physical location of your business, including your business name.
Do not use a PO Box or Rural Route Number for this address. If you make retail sales, this is the address we will print on your license. If you
have more than one location, attach a sheet listing the additional locations.
16. If sales will be made from various temporary locations, (for example, craft shows), provide the list of these locations. If you do not know
where your next location will be, a general location will be used for registration purposes. As soon as you know the location where your
sales will take place, please notify the Department at businesstaxregister@dor.mo.gov or call (573) 751-5860.
17-19. City Limits or District(s): Determine whether you are inside a city’s limits or a district(s). If you are registering for sales tax, this will ensure
we register you to collect and remit the correct tax rate.
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20. Retail Sales of Certain Items.
r Food Tax: Food or food products for home consumption. http://dor.mo.gov/business/sales/foodtax.php.
r Section 144.049, RSMo, exempts certain back-to-school purchases, such as clothing, school supplies, computers, and other items as defined
by the statute, during a period from 12:01 a.m. the first Friday in August and ending at midnight on the Sunday following.
rBeginning in calendar year 2009, Section 144.526, RSMo, exempts up to $1,500 for certain Energy Star certified appliance purchases, such
as furnaces, clothes washers and dryers, water heaters, trash compactors, dishwashers, conventional ovens, ranges, stoves, air conditioners,
refrigerators and freezers and other items as defined by the statue, during a period from 12:01 a.m. on April 19th and ending at midnight
on April 25th.
rA fifty cent (.50) tire fee applies to the retail sale of all new tires designed for use on trailers and self-propelled vehicles not operated
exclusively on tracks. A fifty cent (.50) battery fee applies to the retail sale of batteries that contain lead and sulfuric acid with a nominal
voltage of at least six volts and are intended for use in motor vehicles and watercraft.
rSection 144.054.2 exempts from state sales tax, state use tax and local use taxes (local sales taxes still apply) electricity, gas, whether
natural, artificial, or propane, water, coal, and energy sources, chemicals, machinery, equipment, and materials used or consumed in the
manufacturing, processing, compounding, mining, or production of any product; used or consumed in processing recovered materials;
or used or consumed in research and development related to manufacturing.
23. Motor Vehicle Leasing Sales Tax: Indicate whether or not your company will lease motor vehicles that were purchased tax exempt
because the exemption for motor vehicles purchased for leasing was claimed. Your company will be responsible for charging the
retail sales rate of tax where the lessee is located. (This includes leases that are completed between a Missouri dealer, as your agent, and
a Missouri customer, even if your out of state company is carrying the lease).
Motor Vehicle Leases from Out of State: Indicate if your company is an out of state company that leases motor vehicles to a Missouri
resident where the lease is entered into outside Missouri and the motor vehicle is delivered to the lessee outside Missouri. Your company
will be responsible for charging the highway sales tax rate where the lessee is located. You will need to provide a list of the lessee’s locations
in Missouri.
24-28. Out-of-State Businesses: Only out-of-state businesses need to complete this section. It helps us determine whether you should report
sales tax, use tax, or withholding tax.
29-31. Corporate Income or Franchise Tax: Businesses taxed as a corporation by the Internal Revenue Service must complete this section.
32-35. Withholding Tax: The withholding tax filing frequency is based upon the amount of withholding tax you will be remitting to the De partment.
If you will be remitting over $9,000 in withholding tax per month, you are required to pay quarter-monthly (weekly). Your payment(s) should
be sent to the De part ment electronically. Currently, there are two methods available for electronic filing and payment:
1.) ACH credit through the Department’s TXP bank project; and
2.) Internet filing through a MyTax Missouri portal account, or business tax guest filing.
For information on electronic filing through ACH credit, visit http://dor.mo.gov/business/electronic.php, send an e-mail to elecfile@dor.mo.gov,
or call (573) 751-3900. For information on electronic filing through the Internet, visit https://mytax.mo.gov.
36. Courtesy Mailing Address: We will mail certain duplicate withholding notices to an address other than your mailing address (for example,
owner address).
37. Transient Employer: If de fined as a transient em ployer pursuant to Title XVIII, Chapter 285.230, RMSo, please calculate the amount of your
bond. If you are unsure if you qualify as a transient employer or require transient employer bond forms, please contact the Taxation Division,
P.O. Box 357, Jef fer son City, MO 65105-0357 or call (573) 751-0459 (TTY (800) 735-2966).
Signature: An owner, officer, partner, member or responsible party must sign the application and be listed as an owner. If a power of attorney
signs the application, you must include a Power of Attorney (Form 2827) signed by an owner listed on the application.
Confidentiality: To ensure your tax records are protected and confidential, the De part ment will not release tax information to anyone who is
not listed in our records as an owner, partner, member, or officer for your business. If your partners, members, or officers change, you must
update your registration with the Department by completing Registration or Exemption Change Request (Form 126), before we can release
tax information to those new partners, members, or officers. If you would like the Department to release tax information to an accountant,
tax preparer, or another individual who is not listed on your account, please complete a Power of Attorney Form. (Visit our website at
http://dor.mo.gov/forms/ to obtain Power of Attorney (Form 2827).
2
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5. Ownership Type rSole Proprietor rPartnership rGovernment rTrust
All ownership types listed below, unless specifically exempted, are required to be registered with the Missouri Secretary of State’s Office (register
at sos.mo.gov or call (866) 223-6535). Your application will not be complete without providing the charter number issued to you by their office.
rLimited Partnership - LP Number __________________________________
rLimited Liability Partnership - LLP Number ___________________________
rLimited Liability Company - LLC Number ____________________________
Taxed as a rDisregarded Entity rPartnership rCorporation
rMissouri Corporation - Missouri Charter No. _________________________
Date Incorporated (MM/DD/YYYY) ___ ___ / ___ ___ / ___ ___ ___ ___
rNon-Missouri Corporation - Missouri Charter No. ______________________
State of Incorporation _________________________ Date Registered in Missouri (MM/DD/YYYY) ___ ___ / ___ ___ / ___ ___ ___ ___
3. Select all tax types for which you are applying:
Sales from a Missouri business location
rRetail Sales
rTemporary Retail Sales (Less than 191 days)
rRetail Liquor or Alcohol Sales
Sales or Purchases from an out-of-state location
r Vendor’s Use
r Consumer’s Use (Missouri purchases
where tax is not collected.)
Missouri Employer Withholding Tax
rRegular Withholding
rDomestic or Household Employee
rTransient Employer*
Corporate Tax
rCorporate Income
rCorporate Franchise
Reason for Application
r New MO Registration
r Purchase of Existing Business
r Reinstating Old Business
r Converted (must have converted
through the Missouri Secretary of
State’s office)
r Court Appointed Receiver
r Other:
Reason for Applying
Answer all questions completely. Incomplete and unsigned applications will delay processing..
Form
2643
Missouri Tax I.D.
Number
(Optional)
Federal Employer
I.D. Number
Department Use Only
(MM/DD/YY)
4. Owner Name (Enter Corporation, LLC or Partnership Name, if applicable)
Address E-mail Address
City State ZIP Code County
If an individual is listed as the owner, you must also provide the following:
Social Security Number Date of Birth (MM/DD/YYYY) Telephone Number
| | | | | | | |
Owner Information
___ ___ / ___ ___ / ___ ___ ___ ___
(___ ___ ___)___ ___ ___-___ ___ ___ ___
Ownership Type
rNot Required to register with Missouri Secretary
of State
r Other
Previous Owner Information
6. Is there a previous owner or operator for the business? rYes* rNo *If yes, the following section must be completed.
Name of Previous Owner or Operator
Physical Location of Previous Business City State ZIP Code
Address of Previous Business City State ZIP Code
Select any of the following that you purchased from the previous owner: r Inventory rFixtures r Equipment rReal Estate
r Other __________________________________________________________________________________________________________
_____________________________________________________________________
Missouri Tax Identification Number
| | | | | | |
Purchase Price
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14605010001
3
* Bond Required
Missouri Tax Registration Application
Print ALL PAGES of Form
Reset ALL PAGES of Form
Please print on white paper only
It is not necessary to type hyphens or dashes.
4
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8. Physical Address City State ZIP Code
Address where you will store your tax records (do not use a P.O. Box for record storage).
Mailing and Storage Address
Which forms do you want mailed to this address?
rAll Tax Types rSales and Use Tax rCorporate Income Tax rEmployer Withholding Tax
Reporting forms and notices will be mailed to this address.
7.
Address (street, rural route or P.O. Box) City State ZIP Code
Company Name if different than owner
Officers, Partners, or Members
9. Provide the officers, partners, or members (L.L.C.) of your business who are responsible for the collection and remittance of tax.
Listing individuals or entities here indicates they have direct supervision or control over tax matters. Attach list if needed.
Name (Last, First, Middle Initial) Title
Social Security Number Federal Employer ID Number (FEIN) Date of Birth (MM/DD/YYYY)
Home Address City
State ZIP Code County Title Begin Date (MM/DD/YYYY)
| | | | | | | |
___ ___/___ ___/___ ___ ___ ___
| | | | | | | |
___ ___/___ ___/___ ___ ___ ___
Name (Last, First, Middle Initial) Title
Social Security Number Federal Employer ID Number (FEIN) Date of Birth (MM/DD/YYYY)
Home Address City
State ZIP Code County Title Begin Date (MM/DD/YYYY)
| | | | | | | |
___ ___/___ ___/___ ___ ___ ___
| | | | | | | |
___ ___/___ ___/___ ___ ___ ___
Representatives
10. Business Tax Accounts: Identify all persons who are not a partner, member (L.L.C), or ofcer of the business that have direct supervision or
control over tax matters whom you authorize the Department to discuss your tax matters. Attach list if needed.
Title Begin or End Date (MM/DD/YYYY) Name (Last, First, Middle Initial)
Title Social Security Number Birthdate (MM/DD/YYYY)
Home Address
City State ZIP Code County
| | | | | | | |
__ __ / __ __ / __ __ __ __
__ __ / __ __ / __ __ __ __
Retail Sales, Consumer’s or Vendor’s Use Tax
11. Taxable Sales or Purchases Begin Date (MM/DD/YYYY) ___ ___/___ ___/___ ___ ___ ___
12. Temporary License (Less than 191 days) (MM/DD/YYYY)
(Example: fireworks, temporary event, etc.) Begins ___ ___/___ ___/___ ___ ___ ___ Ends ___ ___/___ ___/___ ___ ___ ___
13. Seasonal Business: If you do not make taxable sales year round, please check the months that you do.
r January r February r March r April r May rJune r July r August r September r October r November r December
14. Estimated sales and use tax liability (select one). Your selection will determine your return ling frequency.
r Monthly (over $500 a month) r Quarterly ($500 or less a month) r Annually (less than $100 a quarter)
5
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15. Business Name (DBA name: attach list if necessary for additional locations)
Street, Highway (Do not use P.O. Box Number or Rural Route Number) City
County State ZIP Code Business Telephone Number
rRetail _____% rWholesale _____% rService _____% rManufacturer rContractor rOther _______________
17. Is this business located inside the city limits of any city or municipality in Missouri?
To verify go to https://mytax.mo.gov/rptp/portal/home/business/salesUseTaxRateInformation
rNo rYes — Specify the city: ______________________________________________________________________ ___
18. Is this business located inside a district(s)? For example, ambulance, fire, tourism, community or transportation development.
rNo rYes — Specify the district name(s): ________________________________________________________________
19. Describe the business activity, stating the major products sold and services provided. ___________________________________________
_________ _______________________________________________________________________________________________________
16. Will sales be made at various temporary locations in Missouri?
rNo rYes—Attach a list of all known locations. If no Missouri location is given during initial registration, a general location will be used.
Business Name and Physical Location
(___ ___ ___)___ ___ ___-___ ___ ___ ___
Business Activity
20. Do you make retail sales of the following items? Select all that apply.
rAlcoholic Beverages rAlternative Nicotine rCigarettes or Other Tobacco Products rDomestic Utilities
rE-Cigarettes or Vapor Products rFood Subject to Reduced State Food Tax Rate rItems Qualifying for Show Me Green Sales Tax Holiday
rItems Qualifying for Back-To-School Sales Tax Holiday http://dor.mo.gov/business/sales/taxholiday/ rLead-Acid Batteries
rNew Tires r Post-Secondary Educational Textbooks rTelecommunication Services
rQualifying Utilities or Items Used or Consumed in Manufacturing or Mining, Research and Development, or Processing Recovered Materials.
21. Do you make retail sales of aviation jet fuel to Missouri customers? ........................................................................................... r Yes rNo
If yes, are your sales made at:
rA Missouri airport? rA location outside Missouri and the fuel is transported into Missouri?
If yes, is the airport located in Missouri and identied on the National Plan of Integrated Airport Systems (NPIAS)? ................ r Yes rNo
If yes, provide a list of applicable locations. _____________________________________________________________________________
22. Do you use, store, or consume aviation jet fuel in Missouri where the seller does not collect tax? ............................................. r Yes rNo
If yes, is the fuel stored, used, or consumed in an airport that is identied on the NPIAS? ......................................................... r Yes rNo
If yes, provide a list of applicable locations: _____________________________________________________________________________
23. Do you lease or rent motor vehicles that were purchased sales tax exempt, to Missouri customers? ........................................ r Yes rNo
If you are an out-of-state company, will you lease motor vehicles to a Missouri resident where the lease is entered into
outside Missouri and the motor vehicle is delivered outside Missouri? ........................................................................................ r Yes rNo
Out-of-State Company
24. Do you have a location or job site in Missouri? .......................................................................................................................... rYes rNo
If yes, attach a list of your locations including address, city, state, zip code and indicate if the location is inside or outside
the city limits. ____________________________________________________________________________________________________
25. Are orders taken from your Missouri customers by telephone, non-resident salesmen, etc.? If resident salesmen, attach
a list where they live and indicate if they are inside or outside the city limits............................................................................. r Yes rNo
26.
Do your representatives who reside in Missouri:
A. Approve customer orders? ..................................................................................................................................................... rYes rNo
B. Make on the spot sales? ........................................................................................................................................................ rYes rNo
C. Maintain an inventory? ........................................................................................................................................................... rYes rNo
D. Deliver merchandise to the customer? .................................................................................................................................. rYes rNo
27.
Do you have non-resident representatives, agents, or temporary employees coming into Missouri on a regular basis? ......... rYes rNo
If yes, define the activities performed while in Missouri. ___________________________________________________________________
___________________________________________________________________________________________________
28. Do you have real or tangible personal property in Missouri? ..................................................................................................... rYes rNo
If yes, please describe: ___________________________________________________________________________________
If you are an out-of-state entity doing business in Missouri, please answer the following questions. .
6
Condentiality of Tax Records
Corporate Income Tax
29. Is this corporation registered with the Internal Revenue Service as a r Regular or Close Corporation r Sub Chapter S Corporation
30. Corporation Tax Begin Date in Missouri (MM/DD/YYYY) Corporation Taxable Year End (MM/DD)
___ ___/___ ___/___ ___ ___ ___ ___ ___/___ ___
31. Will the corporation be required to make quarterly estimated Missouri income tax payments? If the Missouri estimated
tax is expected to be at least $250, or 6.25% of the Missouri taxable income, check the “Yes” box. ...................................... r Yes r No
Mail to: Taxation Division Phone: (573) 751-5860
P.O. Box 357 Fax: (573) 522-1722
Jefferson City, MO 65105-0357 E-mail: businesstaxregister@dor.mo.gov
Visit
http://dor.mo.gov/business/register/
for additional information.
37. Are you a transient employer? ..................................................................................................................................................................... r Yes r No
An employer not domiciled in Missouri and temporarily transacting business in Missouri for less than 24 consecutive months is defined as a transient employer.
(Example: contractor, temporary staffing agency, etc.). For additional information, contact the Department at businesstaxregister@dor.mo.gov or call
(573) 751-0459. If you have indicated that you are a transient employer, you must complete the entire Employer Withholding Tax Section above.
A transient employer must submit the following with this application:
• A completed insurance certification slip indicating Missouri as a covered state for worker’s compensation
• Missouri Employment Security Account number, if hiring a Missouri resident: (first seven digits required)
• Your Missouri Certificate of Authority Number issued by the corporate division of the Missouri Secretary of State’s Office
• A Transient Employer Bond not less than $5,000
Calculate your transient employer bond:
A. Missouri withholding tax Monthly gross wages _______________________ X 5.4% = _____________________ X 3 = ____________________________ (a)
B. Missouri unemployment tax Average # of workers __________ X $7,000 = __________________ X 3.38% __________________ / 4 = ___________________ (b)
(a) ___________________________ + (b) ___________________ = ______________________________ (amount of bond - minimum $5,000)
Visit http://dor.mo.gov/forms/index.php?category=13 for bond forms.
Type of bond r Cash Bond (Form 332) r Certicate of Deposit (Form 4172) r Irrevocable Letter of Credit (Form 2879) r Surety Bond (Form 331)
Withholding Tax Courtesy Mailing Address (a copy of all withholding tax delinquent notices will be mailed to this address)
Transient Employer
Employer Withholding Tax
32. Missouri Withholding Begin Date (MM/DD/YYYY) How many of your employees will work in Missouri?
___ ___/___ ___/___ ___ ___ ___
33. Estimated employer withholding tax liability (select one). Your selection will determine your return filing frequency.
Estimated monthly gross wages _____________________ X 5.4% = __________________________
r Annually (less than $100 withholding tax per quarter) r Monthly ($500 to $9,000 withholding tax per month)
r Quarterly ($100 withholding tax per quarter to $499 r Quarter-Monthly (weekly) (over $9,000 withholding tax per month; required
per month) to pay electronically)
34. Does a parent company le withholding tax reports and receive full compensation for timely led returns? ................................... r Yes r No
35. If you do not pay wages year round, please check the months that you do pay wages.
r January r February r March r April r May rJune r July r August r September r October r November r December
36. Business Name (DBA name)
Street, Route or P.O. Box City
County State ZIP Code Business Telephone Number
(___ ___ ___)___ ___ ___-___ ___ ___ ___
Signature
Missouri Statute 32.057, RSMo, states that all tax records and information maintained by the Missouri Department of Revenue are confidential. The tax information can
only be given to the owner, partner, member, or officer who is listed with us as such. If you wish to give an employee, attorney, or accountant access to your tax information,
you must supply the Department with a power of attorney to grant the authority to release confidential information to them. Visit http://dor.mo.gov/forms to obtain a
Power of Attorney (Form 2827).
Signature Title Date (MM/DD/YYYY)
Typed or Printed Name E-mail Address
___ ___ / ___ ___ / ___ ___ ___ ___
Under penalties of perjury, I declare that the above information and any attached supplement is true, complete, and correct. This application must be signed by the owner, if the business
is a sole proprietorship, or by an individual listed in the Officer, Partners, or Members section of this application. The signing party is acknowledging that they have direct supervision or
control over tax matters.
Comments:
Form 2643 (Revised 04-2019)
*14605040001*
14605040001
Missouri Employment Security Account Number
No digital signatures allowed
Transient Employer: Missouri Statute 285.230, RSMo, a transient employer must file a bond with the Department unless they meet all the exemption
criteria listed in 285.230(2). The amount of bond shall not be less than the average estimated quarterly withholding and unemployment tax
liabilities of the employer and in no case less than $5,000 nor more than $25,000.
*** Important: If you are a transient employer and fail to file a bond, you are in violation of Missouri law. You may be guilty of a misdeameanor and
penalized up to $5,000 and will not be able to perform work in Missouri.
Cash Bond (Form 332)
1. Fully complete the cash bond form. Owners name must include owner, all partners, corporation, or LLC name.
2. Sign the cash bond form.
3. Forward a cashier’s check, money order, or certified check with the cash bond form. Cash, personal, or company checks are not acceptable.
Surety Bond (Form 331)
1. Owners name must include owner, all partners, corporation, or LLC name.
2. A surety bond must be issued by an insurance company licensed for bonding with the Department of Insurance, State of Missouri.
3. It must be on the form provided by the Department.
4. The form must bear the effective date.
5. It must be signed by an authorized representative of the surety company and the owner, partner, officer, or member.
6. The Surety Bond must be accompanied by a valid Power of Attorney letter, issued by the surety company, authorizing the surety official to sign
the Surety Bond.
7. It must be the original bond. A copy is not acceptable.
Irrevocable Letter of Credit (Form 2879)
1. Owners name must include owner, all partners, corporation, or LLC name.
2. The letter of credit must be issued by a financial banking institution located in the United States.
3. It must be on the form provided by the Department.
4. It must be the original letter of credit. A copy is not acceptable.
5. It must state the owner’s name.
6. It must state the date of issuance.
7. It must be signed by a bank official and notarized.
8. It must be accompanied by an “Authorization for Release of Confidential Information” form which must be signed by the owner, partner, officer, or
member and notarized.
Certificate of Deposit (Form 4172)
1. The Certificate of Deposit must be issued by a state or federally chartered financial institution.
2. The Certificate of Deposit must be issued in the name of the Missouri Department of Revenue and the owner, all partners, corporation name or
limited liability company name.
3. It must be issued for not less than 24 months.
4. It must be accompanied by the “Assignment of Certificate of Deposit” form provided by the Department which must be completed by the
financial institution.
5. The Certificate of Deposit must be endorsed or accompanied by a signed withdrawal slip.
6. The actual Certificate of Deposit, Assignment of Certificate of Deposit, and a copy of the signature card must be forwarded with the
registration application.
Sales and Use Tax and Transient Employer Bond Information
Form 2643 (Revised 04-2019)
*14000000001*
14000000001
7
Form
332
________________________________________________________________(Taxpayer) hereby files with the
Missouri Department of Revenue this cash bond and the attached cashier’s check or money order in the amount of
___________________________________________________________________ ($___________________________).
Taxpayer understands that it is required to comply with all the provisions of any statutorily or constitutionally authorized state
or local tax.
If Taxpayer becomes delinquent and owes the Department the above indicated tax, related fees, interest, additions to tax,
and penalties due the state of Missouri, the Director of Revenue may forfeit this bond and apply it to any unpaid
delinquencies.
Delivery of any demands, notice, or service of process by the Department shall be deemed sufficient and made in the
state of Missouri if personally served or if mailed by U.S. mail to the taxpayer or business address as set forth above.
This cash bond and any legal action pertaining thereto shall be governed by and construed in accordance with the laws of
the state of Missouri. The parties understand and agree that the exclusive jurisdiction for any action concerning this bond
shall be the state of Missouri and the only venue shall be in the Circuit Court of Cole County, Missouri.
By signing this cash bond, the undersigned states that he or she has authority to bind the taxpayer or business identified
herein.
Owner, Partner, Corporate Officer or LLC Member Date (MM/DD/YYYY)
__ __ / __ __ / __ __ __ __
Sign
Amount (U.S. Currency - No personal or company checks) Date (MM/DD/YYYY)
At the request of Taxpayers or Business (Owner’s name, all Partners, Corporation, or LLC Name)
Taxpayer or Business Owner’s Address City
County State Zip Code E-mail Address
__ __ / __ __ / __ __ __ __
$
Form 332 (Revised 02-2015)
Mail to:
Sales and Use or Transient Employer
Withholding Motor Fuel Tax Cigarette Tax Other Tobacco Products
Taxation Division Taxation Division Taxation Division Taxation Division
P.O. Box 357 P.O. Box 300 P.O. Box 811 P.O. Box 3320
Jefferson City, MO 65105-0357 Jefferson City MO 65105-0300 Jefferson City MO 65105-0811 Jefferson City, MO 65105-3320
Phone: (573) 751-5860 Phone: (573) 751-2611 Phone: (573) 751-7163 Phone: (573) 751-5772
Fax:
(573) 522-1722 Fax: (573) 522-1720 Fax: (573) 522-1720 Fax: (573) 522-1720
E-mail: businesstaxregister@dor.mo.gov
E-mail: excise@dor.mo.gov E-mail: excise@dor.mo.gov E-mail: excise@dor.mo.gov
Visit http://dor.mo.gov/business/register/ for additional information. TTY (800) 735-2966
Select only one:
r Sales and Use Tax r Motor Fuel Tax
r Other Tobacco Products Motor Fuel license type (Select One):
r Cigarette Tax r Supplier or Permissive Supplier r Distributor
r Transient Employer Withholding and Unemployment Tax r Terminal Operator r Transporter
Cash Bond Type
Personal or company checks will not be accepted as payment. Please remit a cashier’s check or money order.
*14602010001*
14602010001
Department Use Only
(MM/DD/YY)
Federal Employer
I.D. Number
Cash Bond
Missouri Tax I.D.
Number
(Optional)
Please print on white paper only
No digital signatures allowed
Amount (U.S. Currency) Bond Number Issue Date (MM/DD/YYYY)
$ ___ ___ /___ ___ /___ ___ ___ ___
At the Request of Taxpayer or Business (Owner’s Name, All Partners, Corporation, or LLC Name) County
Taxpayer or Business Owner Address City State Zip Code
__________________________________________________________ (Issuer) hereby issues this Surety Bond (bond) in favor of the Missouri Department of Revenue,
in the aggregate sum of __________________________________________________________________________ dollars ($ _______________________ ). This
bond shall secure the payment of the above indicated tax and related fees, interest, additions to tax, and penalties due the state of Missouri or the Department on or after
the date of this bond.
The funds shall be paid to the Department upon a written demand for payment on the Issuer by referencing this bond. The demand for any payment shall be sent by U.S.
mail. The Issuer shall upon receipt honor all partial or full demands for payment and make payment to the Department within thirty (30) days of receipt of the demand.
The surety may cancel the bond by delivering sixty (60) days written notice to the Department. Any election to cancel this bond shall not relieve, release, or discharge the
Issuer from any liability for the indicated taxes, related fees, interest, additions to tax, and penalties of the taxpayer or business that may accrue for all periods prior to the
cancellation of the bond.
The Department shall have a period of one year after the expiration or cancellation date of the sales, use, transient employer withholding and unemployment tax bond to
make a demand for payment upon the Issuer.
The Department shall have a period of 3 years after the expiration or cancellation date of the motor fuel, cigarette and other tobacco products tax bond to make a demand
for payment upon the issuer.
This agreement and any legal action pertaining thereto shall be governed by and construed in accordance with the laws of the state of Missouri. The parties understand
and agree that the exclusive jurisdiction for any action concerning this bond shall be the state of Missouri and the only venue shall be in the Circuit Court of Cole County,
Missouri. The Issuer understands and agrees that the surety shall be liable for prejudgment interest and attorney fees if it breaches its obligations under this bond.
The person signing this bond states that he or she has the legal authority to enter into this bond and to legally bind the taxpayer or business below.
Surety Name Surety Phone Number Surety Company Certificate of Authority Number
Surety Officials Name Typed or Printed Signature of Surety Official
Surety Address City State Zip Code
(___ ___ ___)___ ___ ___-___ ___ ___ ___
Requirements
• Issued by licensed surety company
• Signed by surety company’s authorized representative
• Signed by taxpayer’s authorized representative
• Include an effective date
• Include a valid Power of Attorney issued
by the surety company.
Select One:
r Sales and Use Tax r Motor Fuel Tax
r Cigarette Tax Motor Fuel license type (Select One):
r Other Tobacco Products r Supplier or Permissive Supplier r Distributor
r Transient Employer Withholding Tax r Terminal Operator r Transporter
Authorization for release of confidential information has been set forth at the request of the Department and does not constitute a part of, or an exhibit to, the surety bond.
I hereby authorize release of confidential tax information to the issuing Surety Company listed above for the purpose of making demand for payment on the Surety Bond
Number listed above as long as the obligation remains in force and effect. Release of this information to the named surety company does not give the surety company
authority to request information other than information concerning the delinquent periods for which a demand for payment is being made. I also release the Director of
Revenue and Department of Revenue personnel from any and all liability pursuant to any disclosure of confidential tax information that is necessary for making demand
for or receiving such payment. By signing this Authorization, I state that I have the legal authority to bind the taxpayer or business below.
In witness whereof, this taxpayer or business duly executed the foregoing this _______ day of ________________ , 20_____.
Taxpayer or Business Owner (Proprietorship, Partnership, Corporation or LLC) Title Phone Number
(___ ___ ___)___ ___ ___-___ ___ ___ ___
Signature of Owner, Partner, Corporate Officer, or Member Print or Type Name of Person Signing This Release E-mail address
Form 331 (Revised 02-2015)
Mail To: Sales and Use or Transient Employer
Withholding Tax Motor Fuel Tax Cigarette Tax Other Tobacco Products
P.O. Box 357 P.O. Box 300 P.O. Box 811 P.O. Box 3320
Jefferson City, MO 65105-0357 Jefferson City MO 65105-0300 Jefferson City MO 65105-0811 Jefferson City, MO 65105-3320
Phone: (573) 751-5860 Phone: (573) 751-2611 Phone: (573) 751-7163 Phone: (573) 751-5772
Fax: (573) 522-1722 Fax: (573) 522-1720 Fax: (573) 522-1720 Fax: (573) 522-1720
E-mail: businesstaxregister@dor.mo.gov E-mail: excise@dor.mo.gov E-mail: excise@dor.mo.gov E-mail: excise@dor.mo.gov
*14601010001*
14601010001
Authorization
Bond Type
Department Use Only
(MM/DD/YY)
Federal Employer
I.D. Number
Form
331
Surety Bond
Missouri Tax I.D.
Number
(Optional)
Please print on white paper only
No digital signatures allowed
r Sales and Use Tax r Cigarette Tax r Motor Fuel Tax
r Other Tobacco Products r Transient Employer Withholding and Unemployment Tax
___________________________________________________________________________________(Issuer)
hereby issues this Irrevocable Letter of Credit (ILC) in favor of the Missouri Department of Revenue, in the aggregated sum of
________________________________________________________________________________________________ dollars
($__________________________). This ILC shall secure the payment of the above indicated tax and related fees, interest,
additions to tax, and penalties due the state of Missouri on or after the date this ILC is issued.
The funds shall be paid to the Department upon a written demand for payment on the Issuer referencing this ILC. A demand for any
payment shall be sent by U.S. mail or personal service. The Issuer shall upon receipt honor all partial or full demands for payment
and make payment to the Department within thirty (30) days of receipt of the demand.
This ILC shall be effective for a period of one year from the date of issuance and shall automatically renew for additional one-year
periods unless at least sixty (60) days prior to any such expiration date the Issuer notifies the Department in writing at the address
indicated for each type of tax shown above that it does not elect to renew this ILC. Any election not to renew the ILC shall not
operate to relieve, release or discharge the Issuer from any liability for the indicated tax or taxes and related fees, interest, additions
to tax, and penalties of the taxpayer or business that may accrue for all periods prior to the cancellation of the ILC.
The Department shall have a period of one year after the expiration date of the ILC to make a demand for payment upon the Issuer.
The Issuer affirms that any demand for payment made by the Department in accordance with the terms of this ILC shall be honored
upon receipt.
This agreement and any legal action pertaining thereto shall be governed by and construed in accordance with these terms and the
laws of the State of Missouri. The parties understand and agree that the exclusive jurisdiction for any action concerning this ILC shall
be the state of Missouri and the only venue shall be in the Circuit Court of Cole County, Missouri. The Issuer understands and agrees
that it shall be liable for prejudgment interest and attorney fees if it breaches its obligations under this ILC.
The person signing this ILC states that he or she has the legal authority to enter into this ILC and to legally bind the taxpayer or
business below.
Amount (U.S. Currency) Letter of Credit Number Date of Issuance (MM/DD/YYYY)
At the request of Taxpayer or Business (Owner’s name), all Partners, Corporation, or LLC Name
Taxpayer or Business Owner’s Address City
County State Zip Code E-mail Address
__ __ / __ __ / __ __ __ __
Issuing Bank or Financial Institution Address
City, State, Zip Code Telephone Number
(___ ___ ___)___ ___ ___-___ ___ ___ ___
Signature and Title of Bank or Financial Institution Official Bank Official’s Typed or Printed Name
*14608010001*
14608010001
Tax
Type
Bank or Financial
Institution
Department Use Only
(MM/DD/YY)
Federal Employer
I.D. Number
Missouri Tax I.D.
Number
(Optional)
Irrevocable Letter of Credit
Form
2879
Please print on white paper only
No digital signatures allowed
The following Authorization for Release of Confidential Information has been set forth at the request of the Missouri Department
of Revenue and does not constitute a part of, or an exhibit to, the Irrevocable Letter of Credit on the reverse side of this form
.
I hereby authorize release of confidential tax information to ______________________________________________________
for the purpose of making demand for payment on Irrevocable Letter of Credit Number ________________________________
as long as the obligation remains in force and effect. Release of this information to the named banking institution does not give the
banking institution authority to request information other than information concerning the delinquent periods for which a demand for
payment is being made. I also release the Director of Revenue and Department of Revenue personnel from any
and all liability pursuant to any disclosure of confidential tax information that is necessary for making demand for or receiving such
payment. By signing this Authorization, I state that I have the legal authority to bind the taxpayer or business below.
In witness whereof, this taxpayer or business duly executed the foregoing this ______ day of _________________, 20 ______.
(Bank or Financial Institution)
Mail to:
Sales and Use or Transient Employer
Withholding Tax Motor Fuel Tax Cigarette Tax Other Tobacco Products
Taxation Division Taxation Division Taxation Division Taxation Division
P.O. Box 357 P.O. Box 300 P.O. Box 811 P.O. Box 3320
Jefferson City, MO 65105-0357 Jefferson City MO 65105-0300 Jefferson City MO 65105-0811 Jefferson City, MO 65105-3320
Phone: (573) 751-5860 Phone: (573) 751-2611 Phone: (573) 751-7163 Phone: (573) 751-5772
Fax: (573) 522-1722 Fax: (573) 522-1720 Fax: (573) 522-1720 Fax: (573) 522-1720
E-mail: businesstaxregister@dor.mo.gov E-mail: excise@dor.mo.gov E-mail: excise@dor.mo.gov E-mail: excise@dor.mo.gov
Visit http://dor.mo.gov for additional information. TTY (800) 735-2966
Signature of Owner, Partner, Corporate Officer, or Member Typed or Printed Name of Person Signing this Release
Title Date (MM/DD/YYYY)
___ ___ / ___ ___ / ___ ___ ___ ___
Signature
Form 2879 (Revised 02-2015)
Subscribed and sworn before me, this
day of year
State County (or City of St. Louis) My Commission Expires
Notary Public Signature
Notary Public Name (Typed or Printed)
Embosser or black ink rubber stamp seal
Notary Public
Authorization for Release of Confidential
Information
*14608020001*
14608020001
I,_______________________________________________________________________, being of lawful age, assign and transfer the
Certificate of Deposit (CD) for ___________________________________________________________________________________
($ ____________________), Certificate of Deposit Number ____________________, issued ________________________, 20____,
by________________________________, located at ______________________________________________________________
__________________________________, as security to the Missouri Department of Revenue (Department) in lieu of a cash bond.
This CD shall secure the payment of the above indicated tax and related fees, interest, additions to tax, and penalties due the state of
Missouri on or after the date this CD is issued.
I understand that at any time a delinquency occurs, the Department may redeem the CD assigned by this instrument and apply
the proceeds to such delinquency. I agree that Administrative Rules and Revised Statutes of Missouri will govern my rights and
responsibilities under this assignment. If I have not maintained a satisfactory tax compliance, and my CD is automatically renewable,
the Department will allow the CD to renew. I understand that I will be notified when the Department elects to renew my CD.
Service of process shall be deemed sufficient and made in the state of Missouri if mailed by U.S. mail to the Financial Institution’s address
as set forth above. This agreement and any legal action pertaining thereto shall be governed by and construed in accordance with these
terms and the laws of the state of Missouri. The parties understand and agree that the exclusive jurisdiction for any action concerning
this CD shall be the state of Missouri and the only venue shall be in the Circuit Court of Cole County, Missouri. The undersigned bank
understands and agrees that it shall be liable for prejudgment interest and attorney fees if it breaches its obligations under this CD.
I have read the foregoing and fully understand it and certify that I am the taxpayer subject to this assignment or I have the authority to
execute this assignment on behalf of the Taxpayer.
r Sales and Use Tax r Cigarette Tax r Motor Fuel Tax
r Other Tobacco Products r Transient Employer Withholding and Unemployment Tax
Tax
Type
Business Name
Owner, Ofcer, Partner, or Member Signature Title
Taxpayer
of Record
Bank Phone Number By (Signature of Banking Official)
(___ ___ ___)___ ___ ___-___ ___ ___ ___
Bank Official’s Name Title
Select One:
r The paper Certificate of Deposit is attached.
r The Certificate of Deposit is paperless. A withdrawal slip, confirmation of withdrawal, or endorsement on the Certificate of Deposit is not
required. In the event that taxpayer becomes delinquent, and the Department seeks the redemption of the Certificate of Deposit, a written
request from the Department together with this Assignment is the only documentation necessary to release funds to the Department.
Financial Institution
Acknowledgement
Owner’s Name, all Partners, Corporation, or LLC Name E-mail Address
Business Address City State ZIP Code
Taxpayer or Business Owner’s Address City State ZIP Code
*14609010001*
14609010001
Department Use Only
(MM/DD/YY)
Federal Employer
I.D. Number
Missouri Tax I.D.
Number
(Optional)
Form
4172
Assignment of Certificate of Deposit
Please print on white paper only
Reset Form
Print Form
Enter Owner's Name in front of "and Missouri Department of Revenue"
and Missouri Department of Revenue
No digital signatures allowed
Authority to release the Certificate of Deposit is hereby granted this _____________________________________________
day of _______________________________________ 20 ______. Please mail any proceeds from the Certificate of Deposit
to _________________________________________________________________________________________________.
Missouri Department of Revenue
By: _________________________________________
Title: ________________________________________
Release
The Department will accept a Certificate of Deposit (CD) issued by a state or federally chartered financial institution in lieu of
a Cash Bond subject to the provisions of Revised Statutes of the State of Missouri.
Certificate
of Deposit
• Form 4172 must be fully completed by the financial institution.
• It must be issued jointly in the name of the owner and the Missouri Department of Revenue.
• The bank official’s signature must be notarized.
• Form 4172 must be signed by the sole owner, partner, corporate officer, or member.
• Attach a completed signature card, if required by financial institution.
• Send all completed required documents to the address on Form 4172.
Assignment of CD
Requirements
• A paper CD must be:
• Issued jointly in the name of the owner and the Missouri Department of Revenue;
• A 12-month (2 year) CD; and
• Endorsed in ink by the owner.
• If the CD is a “Book Entry” CD, a signed withdrawal slip or a letter from the issuing financial institution indicating how the
Department of Revenue may draw upon the CD must accompany this form. The sole owner, a partner, a corporate officer,
or a member of a limited liability company must sign the withdrawal slip.
• If the CD is paperless, check the appropriate box.
• The interest derived from the CD must be compounded. If a delinquency occurs, the Department may redeem the CD.
Any proceeds from the CD exceeding the delinquency, including interest proceeds, will be converted to a cash bond.
• The Financial Institution must honor upon receipt all demands for payment and make payment to the Department within
thirty (30) days of receipt of the demand.
Certificate of Deposit Requirements
Visit http://dor.mo.gov/business/register for additional information.
Mail to:
Sales and Use or Transient
Employer Withholding Tax Motor Fuel Tax Cigarette Tax Other Tobacco Products
Taxation Division Taxation Division Taxation Division Taxation Division
PO Box 357 PO Box 300 PO Box 811 PO Box 3320
Jefferson City, MO 65105-0357 Jefferson City, MO 65105-0300 Jefferson City MO 65105-0811 Jefferson City MO 65105-3320
Phone: (573) 751-5860 Phone: (573) 751-2611 Phone: (573) 751-7163 Phone: (573) 751-5772
Fax: (573) 522-1722 Fax: (573) 522-1720 Fax: (573) 522-1720 Fax: (573) 522-1720
E-mail: businesstaxregister@dor.mo.gov E-mail: excise@dor.mo.gov E-mail: excise@dor.mo.gov E-mail: excise@dor.mo.gov
Form 4172 (Revised 04-2018)
Subscribed and sworn before me, this
day of year
State County (or City of St. Louis) My Commission Expires
Notary Public Signature
Notary Public Name (Typed or Printed)
Notary Public
Embosser or black ink rubber stamp seal
*14609020001*
14609020001
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2643 Form 2643 - Missouri Tax Registration Application

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Completed 7 July 2020

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