Form Mo W-4c - Withholding Affidavit For Missouri Residents - Missouri Department Of Revenue

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MISSOURI DEPARTMENT OF REVENUE
FORM
EMPLOYER: Retain this Form MO W-4C for your
TAXATION BUREAU
MO W-4C
records. The Department of Revenue may
WITHHOLDING AFFIDAVIT
request a copy for verification, if necessary.
FOR MISSOURI RESIDENTS
(REV. 11-2007)
THIS FORM IS TO BE COMPLETED BY A MISSOURI RESIDENT EMPLOYED IN A FOREIGN STATE.
I, the undersigned, hereby swear the following information is true and correct. I am a resident of the state of Missouri and an employee of
NAME OF EMPLOYER
EMPLOYER’S MISSOURI ID NUMBER
___ ___ ___ ___ ___ ___ ___ ___
ADDRESS
CITY, STATE, ZIP CODE
I realize that a Missouri resident is required to file an individual income tax return with the Missouri Department of Revenue by April 15 of
each year and report income from all sources. For withholding purposes however;
1. 100% of services for this employer are performed in the state of
, and income taxes are being
withheld by this employer for that state. I will attach to my Missouri individual income tax return, a copy of the return I file with that state.
Based on this sworn information, I hereby request no Missouri income tax be withheld from my wages.
2. _______ % of services for this employer are performed in the state of Missouri and are subject to Missouri withholding tax. Based on
this sworn information, I hereby request that Missouri tax be withheld on this pro rata share.
NAME
SOCIAL SECURITY NUMBER
___ ___ ___ - ___ ___ - ___ ___ ___ ___
ADDRESS
CITY, STATE, ZIP CODE
SIGNATURE
DATE
__ __ / __ __ / __ __ __ __
This publication is available upon request in alternative accessible format(s). TDD 1-800-735-2966
MO 860-0515 (11-2007)

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