Fillable Missouri Tax Registration Applicaiton Small Businesses Only - 2643MO

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Missouri Tax Registration Applicaiton Small Businesses Only - 2643MO

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Congratulations on your new business venture!
Below is some information that you may nd useful in starting your new business.
This application is for sole proprietor or general partnership businesses. If you are a different ownership type
(LLC or INC), you will need to le a 2643A.
Prior to submitting your New Business Application
• Do you have employees, not including yourself, in Missouri or plan to have employees that you will be
withholding state and federal taxes from their paycheck?
If yes, before registering with the Missouri Department of Revenue, you will need to register for a FEIN
with the IRS.
irs.gov/businesses/small-businesses-self-employed/apply-for-an-employer-identication-number-ein-online
Then, you will need to register for withholding tax with the Missouri Department of Revenue, once you
have received your FEIN from the IRS.
• Do you make sales in Missouri to customers in Missouri?
If yes, you will need to register with the Missouri Department of Revenue for Retail Sales tax
• Do you make purchases of tangible personal property from outside of Missouri for use, storage, or con-
sumption in your business?
If yes, you will need to register for consumer's use tax with the Missouri Department of Revenue
IMPORTANT - once you are registered for any tax type with the Missouri Department of Revenue, you will be
required to le a tax return in accordance with your ling frequency even if you have zero to report and remit.
Ownership Type:
r Sole Proprietor r Partnership
Answer all questions completely. Incomplete and unsigned applications will delay processing..
Missouri Tax Registration
Application Small Businesses
Missouri Tax I.D.
Number
(Optional)
Federal Employer
I.D. Number
Department Use Only
(MM/DD/YY)
2a. Owner Name
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/Partner Information
___ ___ / ___ ___ / ___ ___ ___ ___
(___ ___ ___)___ ___ ___-___ ___ ___ ___
r General r Regular
Previous Owner Information
3. 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
1
*14606010001*
14606010001
For Missouri Businesses
ONLY
1. 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
Missouri Employer Withholding Tax
r Regular Withholding
r Domestic or Household Employee
Reason for Application
r New MO Registration r Other:
r Purchase of Existing Business
r Reinstating Old Business
Reason for Applying
2b. Owner Name
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
| | | | | | | |
___ ___ / ___ ___ / ___ ___ ___ ___
(___ ___ ___)___ ___ ___-___ ___ ___ ___
Form
2643-MO
Please print on white paper only
It is not necessary to type hyphens or dashes.
Reset ALL PAGES of Form
Print ALL PAGES of Form
2
Representative
6. Business Tax Accounts: Identify all persons who are not a partner, 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 Use Tax
7. Taxable Sales or Purchases Begin Date (MM/DD/YYYY) ___ ___/___ ___/___ ___ ___ ___
8. Temporary License (Less than 191 days) (MM/DD/YYYY)
(Example: fireworks, temporary event, etc.) Begins ___ ___/___ ___/___ ___ ___ ___ Ends ___ ___/___ ___/___ ___ ___ ___
9. 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
10. 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)
*14606020001*
14606020001
11. 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
12. Will sales be made at various temporary locations in Missouri?
r No r Yes—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
(___ ___ ___)___ ___ ___-___ ___ ___ ___
5. 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 Employer Withholding Tax
Reporting forms and notices will be mailed to this address.
4.
Address (street, rural route or P.O. Box) City State ZIP Code
Company Name if different than owner
r Retail _____% r Wholesale _____% r Service _____% r Manufacturer r Contractor r Other _______________
13. 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
r No r Yes — Specify the city: ______________________________________________________________________ ___
14. Is this business located inside a district(s)? For example, ambulance, fire, tourism, community or transportation development.
r No r Yes — Specify the district name(s): ________________________________________________________________
15. Describe the business activity, stating the major products sold and services provided. ___________________________________________
_________ _______________________________________________________________________________________________________
3
Form 2643-MO (Revised 05-2020)
Business Activity
16. 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 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
*14606030001*
14606030001
Condentiality of Tax Records
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.
Employer Withholding Tax
17. Missouri Withholding Begin Date (MM/DD/YYYY) How many of your employees will work in Missouri?
___ ___/___ ___/___ ___ ___ ___
18. 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)
19. 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
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 s section of this application. The signing party is acknowledging that they have direct supervision or control over
tax matters.
Comments:
No digital signatures allowed
Department Use Only
(MM/DD/YY)
Taxpayer Missouri
Tax I.D. Number
Taxpayer Federal
Employer I.D. Number
All appointed representatives must sign on reverse side of this form.
Taxpayer’s Name or Business Name
Spouse’s Name or if a dba, state the business name Spouse’s Social Security Number
Street Address Missouri Charter Number
City State Zip Code Telephone Number
E-mail Address
(__ __ __) __ __ __ - __ __ __ __
| | | | | | | | |
Name of Appointed Representative Address
Telephone Number E-mail Address
Name of Appointed Representative Address
Telephone Number E-mail Address
Name of Appointed Representative Address
Telephone Number E-mail Address
Name of Appointed Representative Address
Telephone Number E-mail Address
(___ ___ ___)___ ___ ___-___ ___ ___ ___
Representative(s)
(___ ___ ___)___ ___ ___-___ ___ ___ ___
(___ ___ ___)___ ___ ___-___ ___ ___ ___
(___ ___ ___)___ ___ ___-___ ___ ___ ___
r Cigarette or Other Tobacco Products r Corporation Income and Corporation Franchise r Personal Income
r Motor Fuel r Sales or Use r Withholding
r Other _____________________________________________________________________________________________________________________
Tax Type(s)
r All Tax Periods r Tax Year or Period(s) Only ___________________________________________
r Range of Tax r Date of Death (if estate tax) ___ ___ / ___ ___ / ___ ___ ___ ___
Tax Period Beginning ___ ___ / ___ ___ / ___ ___ ___ ___ to Tax Period Ending ___ ___ / ___ ___ / ___ ___ ___ ___
Year(s) and
Period(s)
*14504010001*
14504010001
r All other powers of attorney on file with the Department shall remain in effect, or
r By execution of this power of attorney, all earlier powers of attorney on file with the Department are hereby revoked, except the
following: (specify to whom the power of attorney was granted, date and address, or refer to attached copies of earlier powers of attorney
and authorizations.) Attach additional forms if needed.
Removal of Power
Taxpayer Social
Security Number
| | | | | | | | | |
Only select one of the following:
Form
2827
Power of Attorney
Please print on white paper only
Reset Form
Under penalties of perjury, I (we) hereby certify that I (we) am (are) the taxpayer(s) named herein or that I have the authority to execute this
power of attorney on behalf of the taxpayer(s).
Name Title (if applicable)
Signature Date (MM/DD/YYYY) Taxpayer Telephone Number
Name Title (if applicable)
Signature Date (MM/DD/YYYY) Taxpayer Telephone Number
__ __ / __ __ / __ __ __ __
__ __ / __ __ / __ __ __ __
(___ ___ ___)___ ___ ___-___ ___ ___ ___
Signature
(___ ___ ___)___ ___ ___-___ ___ ___ ___
Printed Name of Representative Signature of Representative Date (MM/DD/YYYY)
___ ___ / ___ ___ / ___ ___ ___ ___
Designation (Please select number from list above) Title (if applicable)
r 1 r 2 r 3 r 4 r 5 r 6 r 7 r 8
Printed Name of Representative Signature of Representative Date (MM/DD/YYYY)
___ ___ / ___ ___ / ___ ___ ___ ___
Designation (Please select number from list above) Title (if applicable)
r 1 r 2 r 3 r 4 r 5 r 6 r 7 r 8
Printed Name of Representative Signature of Representative Date (MM/DD/YYYY)
___ ___ / ___ ___ / ___ ___ ___ ___
Designation (Please select number from list above) Title (if applicable)
r 1 r 2 r 3 r 4 r 5 r 6 r 7 r 8
Printed Name of Representative Signature of Representative Date (MM/DD/YYYY)
___ ___ / ___ ___ / ___ ___ ___ ___
Designation (Please select number from list above) Title (if applicable)
r 1 r 2 r 3 r 4 r 5 r 6 r 7 r 8
Please consult Missouri Regulation 12 CSR 10-41.030 for any questions about who may serve as an attorney(s)-in-fact and what additional
documentation may be required.
I declare that I am aware of Regulation 12 CSR 10-41.030 and that I am authorized to represent the taxpayers identified above for the tax
matters there specified and that I am one of the following:
1. a member in good standing of the bar; 5. a fiduciary for the taxpayer;
2. a certified public accountant duly qualified to practice; 6. an enrolled agent;
3. an officer of the taxpayer organization; 7. tax preparer, or
4. a full-time employee of the taxpayer; 8. other authorized representative or agent
Note: All appointed representatives must sign below. No digital signatures allowed.
Declaration of Representative(s)
Mail to:
(Business Tax) (Personal Tax) (Motor Fuel Tax) (Cigarette or Other Tobacco Products Tax)
Taxation Division Taxation Division Taxation Division Taxation Division
P.O. Box 357 P.O. Box 2200 P.O. Box 300 P.O. Box 811
Jefferson City, MO 65105-0357 Jefferson City, MO 65105-2200 Jefferson City, MO 65105-0300 Jefferson City, MO 65105-0811
Phone: (573) 751-5860 Phone: (573) 751-3505 Phone: (573) 751-2611 Phone: (573) 751-7163
Fax: (573) 522-1722 Fax: (573) 751-2195 Fax: (573) 522-1720 Fax: (573) 522-1720
E-mail: businesstaxregister@dor.mo.gov E-mail: income@dor.mo.gov E-mail: excise@dor.mo.gov E-mail: excise@dor.mo.gov
Visit http://dor.mo.gov/ for additional information.
Form 2827 (Revised 04-2018)
*14504020001*
14504020001
If this is being submitted in response to an audit, please fax to (573) 522-6922.
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Missouri Tax Registration Applicaiton Small Businesses Only - 2643MO

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Completed 4 March 2021

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