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Missouri Department of Revenue

2016 Partnership or S Corporation Withholding

Form

MO-3NR

Exemption or Revocation Agreement

For calendar year Jan. 1 - Dec. 31,_____, or fiscal year beginning ___________, _____ and ending ___________, _____.

Revocation Indicator

Department Use Only

Federal Employer Identification Number

Missouri Tax Identification Number

Partnership

S Corporation

Business Name

Street Address

City

State

Zip Code

E-mail Address

Taxpayer Name

Social Security Number

Street Address

City

State

Zip Code

I, _______________________________________, as a partner or shareholder of the above named partnership or S corporation,

request to be exempt from Missouri income tax withholding on my Missouri distributive share item(s) received through this partnership

or S corporation for the tax year ___________, and all subsequent tax years, until I notify the Department of a change in this election.

By signing this agreement, I agree to:

1) File an individual income tax return in accordance with the provisions of

Section 143.481,

RSMo, and make timely payment

of all taxes imposed on me by this state with respect to the income of the partnership or S corporation for every year in which

I maintain my exemption status; and

2) Be subject to personal jurisdiction in this state for the purpose of the collection of income taxes, together with related interest

and penalties, imposed on me by this state with respect to my distributive share of the income for this partnership or S corporation.

Taxpayer Name

Social Security Number

Street Address

City

State

Zip Code

I, _______________________________________, as a partner or shareholder of the above named partnership or S

corporation, do hereby revoke my previous withholding election dated ___ ___ / ___ ___ / ___ ___ ___ ___. At this time, I

request to be subject to withholding by this partnership or S corporation on my Missouri distributive share item(s) received

through this partnership or S corporation for the tax year ___________, and all subsequent tax years, until I notify the

Department of a change in this election.

Under penalties of perjury, I declare that the above information and any attached supplement is true, complete, and correct.

Signature of Taxpayer

Printed Name

Daytime Telephone

Date (MM/DD/YYYY)

Department Use Only

(

)

___ ___ ___

___ ___ ___ ___

___ ___ / ___ ___ / ___ ___ ___ ___

Form MO-3NR (Revised 12-2016)

Mail to:

Taxation Division

Phone: (573) 751-3505

Visit

P.O. Box 3815

TTY: (800) 735-2966

for additional information.

Jefferson City, MO 65105-3815

Fax: (573) 526-7939

E-mail:

income@dor.mo.gov

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Form Mo-3nr Draft - Partnership Or S Corporation Withholding Exemption Or Revocation Agreement - 2016

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