Form 943 - Request For Tax Clearance

MISSOURI DEPARTMENT OF REVENUE

FORM

REQUEST FOR TAX CLEARANCE

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943

Phone: (573) 751-9268

Fax: (573) 751-9409

E-mail: taxclearance@mail.dor.state.mo.us

(REV. 8-2001)

COMPLETE FORM IN ITS ENTIRETY TO OBTAIN TAX CLEARANCE

TYPE OF OWNERSHIP (PLEASE CHECK ONE)

CORPORATION

SOLE PROPRIETORSHIP

PARTNERSHIP

LIMITED LIABILITY COMPANY

CORPORATION NAME

DOING BUSINESS AS NAME (DBA)

BUSINESS STREET ADDRESS

CITY, STATE, ZIP CODE

NATURE OF BUSINESS

MO TAX IDENTIFICATION NUMBER

FEDERAL EMPLOYER IDENTIFICATION NUMBER

DOES BUSINESS HAVE EMPLOYEES IN MISSOURI?

MISSOURI UNEMPLOYMENT INSURANCE COMPENSATION NUMBER

YES

NO

REASON CLEARANCE IS BEING REQUESTED

DISSOLUTION (REINSTATE)

MERGER AS OF _________________________

FINANCIAL CLOSING

DISSOLUTION (VOLUNTARY)

WITHDRAWAL

LIQUOR LICENSE RENEWAL

TERMINATION

SELL OF BUSINESS (ASSETS)

OTHER __________________________

CORPORATION CHARTER NUMBER

STATE OF INCORPORATION

DATE OF INCORPORATION / CERTIFICATE OF AUTHORITY IN MO

IF A CORPORATION

A corporation is liable for franchise tax if Line 6A or 6B on the Franchise Tax Report is more than $200,000 for years beginning on or after January 1, 1988

through December 31, 1999. Is your corporation liable for Franchise Tax for these years?

YES

NO

IF NO, STATE YEAR(S) WHICH ARE NOT REQUIRED TO BE FILED _____________________________________________

For years beginning on or after January 1, 2000 if the assets of the corporation are less than $1,000,000 a franchise tax is not due, however, it is mandatory

that a Franchise Tax Return be filed.

Did the corporation have a prior name?

YES

NO

If yes, please state the previous name __________________________________________________________________________

Does the corporation file a consolidated corporation income tax return in Missouri?

YES

NO

If yes, give parent name/FEIN _________________________________________________________________________________

HUSBAND’S SOCIAL SECURITY NUMBER

WIFE’S SOCIAL SECURITY NUMBER

IF A SOLE PROPRIETORSHIP

Have you filed individual income tax returns in other states?

NO

YES

If “yes”, what years? ________________________________________________

Have you resided in state(s) where no income tax return is required?

NO

YES

If “yes”, what state(s)? ______________________________________________

If “yes”, what year(s)? ______________________________________________

If “no” explain: __________________________________________________________________________________________________________________________________

How long have you been a Missouri resident? _________________________________________________________________________________________________________

Please attach a listing showing partner’s names, home addresses, and social security numbers/federal employer

IF A PARTNERSHIP

identification numbers.

MISSOURI CIGARETTE WHOLESALER LICENSE NUMBER

MISSOURI MOTOR FUEL LICENSE NUMBER

The Department of Revenue will process your tax clearance and notify you regarding the status of your account. Please note that if the taxpayer owes any

taxes it will be shown on the denial of tax clearance letter issued by the department. This denial of tax clearance will be sent to the person authorized to

receive the tax clearance letter. If your account is clear, a certificate of tax clearance will be issued by the Department of Revenue.

If the requestor is other than an officer of the corporation, the Authorization for Release of Confidential Information section below must be completed before

any information can be disclosed.

Under penalties of perjury I declare that the above information is true, accurate, and complete.

SIGNATURE OF OWNER/OFFICER

TITLE

TELEPHONE NUMBER

(

)

AUTHORIZATION FOR RELEASE OF CONFIDENTIAL INFORMATION

Release of this information to a third party 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 represent the taxpayer before the department, it is necessary for the taxpayer to execute a Power of Attorney designating the third party as its representative.

NAME

TITLE

REPRESENTING

ADDRESS

CITY, STATE, ZIP CODE

PLEASE SEND ORIGINAL TO: MISSOURI DEPARTMENT OF REVENUE, DIVISION OF TAXATION AND COLLECTION, P.O. BOX 3666, JEFFERSON CITY, MO 65105-3666

This publication is available upon request in alternative accessible format(s).

MO 860-0912 (8-2001)