Missouri Form MO W-4C Withholding Affidavit For Missouri Residents Click this button to begin: Begin Instructions: 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: Begin © Copyright 2003-2014, Symmetry Software, all rights reserved Form MO W-4C 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; 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. 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) __ __ /__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.
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