Missouri Withholding Affidavit For Missouri Residents

Withholding Affidavit For Missouri Residents
Form MO W-4C Withholding Affidavit for Missouri Residents
Reset Form

Form

MO W-4C

Print Form
Missouri Department of Revenue
Withholding Affidavit
For Missouri Residents

This form is to be completed by a Missouri resident employed in a foreign state.

Employee

Employer

Employer: Please retain this Form MO W-4C for your records. Do not send a copy to the Department of Revenue unless requested to
do so.

Name

Missouri Tax Identification Number
|

Street Address

City 	

Name

Street Address

|

State 		

|

|

|

|

|

|

|

|

ZIP Code

Social Security Number

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.

Signature

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.

Under penalties of perjury, I declare that the above information and any attached supplement is true, complete, and correct. I am a Missouri
resident and an employee of the employer listed above.
Signature	

Title			

Printed Name	

Date (MM/DD/YYYY)

__ __ /__ __ /__ __ __ __

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

Mail to:	
	
	

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

Phone: (573) 751-8750 				
TDD: (800) 735-2966
Visit http://www.dor.mo.gov/business/withhold
Fax: (573) 522-6816
for additional information.