Missouri Certificate of Nonresidence or Allocation of Withholding Tax

Certificate of Nonresidence or Allocation of Withholding Tax
Form MO W-4A Certificate of Nonresidence or Allocation of Withholding Tax
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MO W-4A

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Missouri Department of Revenue
Certificate of Nonresidence or
Allocation of Withholding Tax

Employee

This form is to be completed by a nonresident who performs a determinable percentage of services within Missouri.
Employer: For information on how this allocation may be determined, please refer to the website listed below.
Employee: This form is to be filed with your employer. Do not send it to the Department of Revenue.
Name of Employee

Street Address

Social Security Number

City 	

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State 		

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ZIP Code

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Signature

I estimate the proportion of services performed within Missouri and subject to the withholding tax to be __________%.
I will notify my employer within 10 days of any substantial change in proportion, or a change in status to resident of Missouri.
Under penalties of perjury, I declare that the above information and any attached supplement is true, complete, and correct. I also declare that I
am a nonresident of the State of Missouri, and reside at the address stated above and perform services partly within and partly without Missouri.
Signature	

Title			

Printed Name	

Date (MM/DD/YYYY)

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Form MO W-4A (Revised 11-2013)

	
Taxation Division	
	
P.O. Box 999	
	
Jefferson City, MO 65108-0999	
		

Phone: (573) 751-8750				
TTY: (800) 735-2966
Visit http://www.dor.mo.gov/business/withhold
Fax: (573) 522-6816
for additional information.
E-mail: [email protected]