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MISSOURI DEPARTMENT OF ECONOMIC DEVELOPMENT

MISSOURI FORM

135 - A

NEW/EXPANDED BUSINESS FACILITY AND ENTERPRISE ZONE:

APPLICATION FOR SUBSEQUENTLY CLAIMING TAX BENEFITS

READ PAGES 18-22 OF INSTRUCTIONS CAREFULLY BEFORE COMPLETING FORM

SCHEDULES S AND M MUST ACCOMPANY THIS APPLICATION WHICH

MUST BE FILED EACH YEAR FOLLOWING YEAR ONE

FOR CALENDAR YEAR _____ OR TAX YEAR BEGINNING _________________ _____, _____, ENDING _________________ _____, _____

NAME OF FACILITY

FACILITY FEDERAL I.D. NO.

AND

PLEASE

ADDRESS OF FACILITY (WHERE DEVELOPMENT OCCURRED)

STREET

TAXPAYER FEDERAL I.D. NO.

TYPE

AND

CITY

COUNTY

ZIP CODE

FACILITY MISSOURI TAX I.D. NO.

(MITS)

MISSOURI

1. Is this address within a designated enterprise zone? (See instructions, page 19)

Yes

1a. List all other federal and state programs for which this facility is applying, or is currently utilizing:

_____________________________________________________________________________________________________

2. Name and mailing address if different than above (See instructions, page 19):

NAME

ADDRESS (STREET, P.O. BOX, CITY, STATE, ZIP CODE)

2a. Name and address of business headquarters if different from above (See instructions, page 19):

_____________________________________________________________________________________________________

3. Name, address and telephone of person completing application (See instructions, page 19):

NAME

TELEPHONE NUMBER

(

)

ADDRESS (STREET, P.O. BOX, CITY, STATE, ZIP CODE)

4. Business entity for tax purposes (See instructions, page 19): 4a.

Corporation 4b.

Fiduciary 4c.

Individual Proprietorship

4d.

Partnership 4e.

S-Corp. 4f.

Limited Liability Corp. 4g.

Limited Liability Partnership 4h.

Other (Specify) _________

NOTE: IF THE TAXPAYER IS A FIDUCIARY, PARTNERSHIP, S-CORPORATION, ETC., IDENTIFY THE NAMES, SOCIAL SECURITY NUMBERS AND PROPOR-

TIONED SHARE OF OWNERSHIP OF EACH BENEFICIARY, PARTNER OR SHAREHOLDER ON THE LAST DAY OF THE TAX PERIOD. AGGREGATE PROPOR-

TIONATE SHARES OR PERCENT OF TOTAL OWNERSHIP MAY NOT EXCEED 100%. ATTACH A SEPARATE SHEET IF NECESSARY.

NAME(S)

SOCIAL SECURITY NO.(S)

% OWNERSHIP YEAR END

–

4i. Taxpayer’s total annual Missouri sales revenues or receipts (See instructions, page 19):

$0 - $250,000

$250,000 - $500,000

$500,000 - $1M

$1M - $5M

$5M - $10M

$10M & over

4j. Taxpayer’s total Missouri employment (See instructions, page 19): __________

5. Describe the business activity(ies) conducted at this facility. Be specific. (See instructions, page 20)

5a. Enter the facility’s 4-digit Standard Industrial Classification (SIC) or 5-digit NAICS number if known (See instructions, pages

19-20): __________

6. Tax years for which this facility’s tax benefit has been certified if known (See instructions, page 20):

Total Amount of Credits

Certified by State

Claimed on MO Return

6a. 1st year: Beginning _________________ , ____ Ending ______________ , ____ $ _____________ $ ____________ 6a

6b. 2nd year: Beginning _________________ , ____ Ending ______________ , ____ $ _____________ $ ____________ 6b

6c. 3rd year: Beginning _________________ , ____ Ending ______________ , ____ $ _____________ $ ____________ 6c

MO 419-1524 (11-04)

MoDED-135-A

Form 135 - A New/expanded Business Facility And Enterprise Zone: Application For Subsequently Claiming Tax Benefits

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