Missouri Form MO W-4C - Symmetry Payroll Forms

Missouri Form MO W-4C
Withholding Affidavit For Missouri Residents
Click this button to begin:
Move the "hand" pointer over a form box on the document. The "hand" should turn into an
"I-beam". The "I-beam" signifies a "fill-in" section to the form. Click inside the box. You can
now type into the box. When the pointer hovers over a check box, button, or item list, it will
turn into a hand with one finger pointing. This means you can select the item.
To move from field to field, use the Tab key. Shift + Tab will move you to the previous field.
Fill out the form by typing text into the appropriate areas and checking boxes where
needed. (Boxes can be checked either by clicking on the box with your mouse, or by
tabbing into the box and hitting the "enter" key.)
Print the form using the "print" button on the form itself - not the print icon or command in
your web browser. If you print using your web browser's print command instead of the
Acrobat button, the contents of the fields might not print properly.
Check the printed forms very carefully for any errors, fields that did not print, or omissions.
You may go back and make changes to any of the fields in your open document, and then
reprint it.
When the form is completed, click on the "Submit" button.
Click this button to begin:
© Copyright 2003-2014, Symmetry Software, all rights reserved
Missouri Department of Revenue
Withholding Affidavit
For Missouri Residents
This form is to be completed by a Missouri resident employed in a foreign state.
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.
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;
Select a State
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.
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.
Printed Name
__ __ /__12/13/2013
__ /__ __ __ __
Print Form
Mail to:
Taxation Division
P.O. Box 999
Jefferson City, MO 65108-0999
Form MO W-4C (Revised 11-2013)
Phone: (573) 751-8750 TDD: (800) 735-2966
Visit http://www.dor.mo.gov/business/withhold
Fax: (573) 522-6816
for additional information.