1. Does this business have Missouri employees for which they are required to withhold Missouri taxes? r Yes r No
2. Do you pay contributions to the Division of Employment Security? r Yes r No If yes, list account number _______________
1. I am completing the following transaction with the Missouri Secretary of State’s Office.
r Reinstatement r Withdrawal or Termination r Merger — Date of Merger
All tax types and the account with the Division of Employment Security will be reviewed and must be filed and paid in full.
2. I am completing the following transaction: r Selling Business Assets r Financial Closing r MBE or WBE
r Missouri Quality Jobs r Office of Administration Contract Bid greater than $1,000,000 (Page 2 is required.)
r Other ___________________________________________________________________________________________
All tax types and the account with the Division of Employment Security will be reviewed and must be filed and paid in full.
3. I require a sales or use tax Certificate of No Tax Due for the following: Select all that apply.
r Business License r Liquor License r Other (if not listed) _____________________________________________________
4. I require a sales or use tax Vendor No Tax Due to obtain or renew a contract with the state of Missouri. (Page 2 is required.)
Contact person ______________________________________________
Reason(s) for Request
___ ___ / ___ ___ / ___ ___ ___ ___
Phone Number ( ___ ___ ___ ) ___ ___ ___-___ ___ ___ ___
Mail to: Taxation Division Phone: (573) 751-9268
P.O. Box 3666 Fax: (573) 522-1265
Jefferson City, MO 65105-3666 E-mail: taxclearance@dor.mo.gov
Signature of Owner or Officer Title Phone Number
Printed Name of Owner or Officer Please fax the results to
( _ _ _ ) _ _ _ - _ _ _ _
( _ _ _ ) _ _ _ - _ _ _ _
Under penalties of perjury, I declare that the above information and any attached supplement is true, complete, and correct.
Signature
Ownership
If there has been a change in the ownership of your business, you may need to contact Business Tax Registration at (573) 751-5860 to ensure
your account is properly registered.
r Corporation r Partnership r Sole Proprietorship
r Limited Liability Company Taxed as: r Corporation r Partnership r Sole Owner
Business
Name Doing Business As Name (DBA)
Mailing Address City State Zip Code
Sole
Proprietorships
Your Social Security Number
| | | | | | | |
Spouse’s Social Security Number
| | | | | | | |
If individual income tax returns have been
previously filed in another state, please
provide a list of the states and years filed. Attach
additional page(s) to this form if needed.
If there has been a name change for this corporation, please provide prior name.
_____________________________________________________________
r This corporation files consolidated corporation income tax returns in Missouri.
Parent Corporation Information:
Missouri corporation franchise tax returns cannot be filed consolidated and must
be filed by each corporation.
Corporations
Federal Employer Identification Number
| | | | | | | |
Missouri Tax Identification Number
| | | | | | |
Authorization
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
E-mail Address of Authorized Person
( _ _ _ ) _ _ _ - _ _ _ _
*15012010001*
15012010001
Form
943
Request for Tax Clearance
Missouri Tax I.D.
Department Use Only
Number
Federal Employer
I.D. Number
Charter
Number
(MM/DD/YY)
Form 943 (Revised 04-2015)
It is not necessary to type hyphens or dashes.
