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                  Form

 4854                    Employer Withholding Tax Refund Request

                  You must receive confirmation from the Department of Revenue that a valid overpayment exists prior to completing this form.
Missouri Tax Identification Number                 Tax Period (YYYY/MM)                                      Overpay Amount 
       |        |        |        |        |        |        |        ____ ____  ____ ____ / ____ ____ 
Federal Employer Identification Number (FEIN)                                  Telephone  Number                                              Department Use Only
       |        |        |        |        |        |        |        |        (____ ____ ____) ____ ____ ____- ____ ____ ____ ____         |          |          |          |          |       
Business Name

Business Address                                                                                  City                                        State               Zip Code 

Provide a detailed description of the reason for overpayment.  (Required)

                  Signature (Required)                                                                                             Date (MM/DD/YYYY)
                                                                                                                                   ___ ___ / ___ ___ / ___ ___ ___ ___
         Signature
                                                                                                                                                       Form 4854 (Revised 05-2014)
Mail to:  Taxation Division                                                     Phone: (573) 751-7200
                      P.O. Box 3375                                             Fax: (573) 522-6816           Visit http://dor.mo.gov/business/withhold/ 
                      Jefferson City, MO 65105-3375                             E-mail:  withholding@dor.mo.gov           for additional information.
                                                                                 
                  Form

 4854                    Employer Withholding Tax Refund Request

                  You must receive confirmation from the Department of Revenue that a valid overpayment exists prior to completing this form.
Missouri Tax Identification Number                 Tax Period (YYYY/MM)                                      Overpay Amount 
       |        |        |        |        |        |        |        ____ ____  ____ ____ / ____ ____ 
Federal Employer Identification Number (FEIN)                                  Telephone  Number                                              Department Use Only
       |        |        |        |        |        |        |        |        (____ ____ ____) ____ ____ ____- ____ ____ ____ ____         |          |          |          |          |       
Business Name

Business Address                                                                                  City                                        State               Zip Code 

Provide a detailed description of the reason for overpayment.  (Required)

                  Signature (Required)                                                                                             Date (MM/DD/YYYY)
                                                                                                                                   ___ ___ / ___ ___ / ___ ___ ___ ___
         Signature
                                                                                                                                                       Form 4854 (Revised 05-2014)
Mail to:  Taxation Division                                                     Phone: (573) 751-7200
                      P.O. Box 3375                                             Fax: (573) 522-6816           Visit http://dor.mo.gov/business/withhold/  
                      Jefferson City, MO 65105-3375                             E-mail:  withholding@dor.mo.gov           for additional information.