Form 8821 - Authorization For Release Of Confidential Information
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FORM
MISSOURI DEPARTMENT OF REVENUE
8821
AUTHORIZATION FOR RELEASE OF
CONFIDENTIAL INFORMATION
(REV. 11-2007)
I,
, authorize and request the Missouri Department of Revenue, to release confidential tax records
pertaining to
for the tax reporting period(s):
I request these records for:
Tax ID Number
Tax ID Number
Corporate Income /
Sales/Use Tax
Franchise Tax
Motor Fuel Tax
Employer Withholding Tax
Financial Institution Tax
Individual Income Tax
(List Social Security Number
Other
under Tax I.D. Number)
The record should be:
Made available for use by me or the specified agent on the 3rd Floor, Truman Building, Jefferson City, Missouri.
Photocopied and copies forwarded to me at: Street:
City, State, Zip:
Photocopied and copies forwarded to the agent specified below.
I SPECIFICALLY AUTHORIZE THE FOLLOWING AGENT TO EXAMINE THE ABOVE IDENTIFIED CONFIDENTIAL TAX RECORDS.
NAME
TITLE
SSN
__ __ __ - __ __ - __ __ __ __
STREET ADDRESS
PHONE
(__ __ __ ) __ __ __ - __ __ __ __
CITY, STATE, ZIP CODE
(COMPLETE THIS SECTION IF REQUESTING CONFIDENTIAL TAX RECORDS
FOR A BUSINESS, CORPORATION, S CORPORATION, OR PARTNERSHIP)
I am authorized to sign this document as an officer, partner, or owner of the corporation or business. This authorization shall be effective
this date and shall expire on
, or until terminated by the undersigned.
For sales tax records only — The Director of Revenue may charge not more than fifty dollars per day for use of facilities within the
division or charge not more than one dollar per page for photocopies of confidential records to defray costs incurred.
The Director of Revenue and department personnel, are hereby released from any and all liability pursuant to unauthorized disclosures of
confidential tax information resulting from release of information under Section 32.057, RSMo or any other applicable confidentiality statute.
UNDER PENALTIES OF PERJURY, I DECLARE THAT I HAVE EXAMINED THIS AUTHORIZATION, AND, TO THE BEST OF MY
KNOWLEDGE AND BELIEF, IT IS TRUE, CORRECT, AND COMPLETE. IF PREPARED BY A PERSON OTHER THAN THE
OWNER, THIS DECLARATION IS BASED ON ALL INFORMATION OF WHICH HE HAS ANY KNOWLEDGE.
OWNER/OFFICER SIGNATURE
DATE
PHONE NUMBER
__ __ / __ __ / __ __ __ __
(__ __ __ ) __ __ __ - __ __ __ __
PRINTED NAME
TITLE
SSN
__ __ __ - __ __ - __ __ __ __
PLEASE SEND COMPLETED FORM TO
Corporate Income / Franchise Tax
Individual Income Tax
All Other Taxes
Missouri Department of Revenue
Missouri Department of Revenue
Missouri Department of Revenue
Business Tax
Personal Tax
Support Services
P.O. Box 3365
P.O. Box 2200
P.O. Box 3022
Jefferson City, MO 65105-3365
Jefferson City, MO 65105-2200
Jefferson City, MO 65105-3022
This publication is available upon request in alternative accessible format(s).
MO 860-0638 (11-2007)
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