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

 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                                                                                                                         Social Security Number
                                                                                |        |        |        |        |        |        |        |               
                  Street Address                                                       City                                                                  State          ZIP Code
        Employee

 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                                                                                 

        Signature Printed Name                                                  Date (MM/DD/YYYY)
                                                                                __ __ /__ __ /__ __ __ __
                                                                                                                                                                     Form MO W-4A  (Revised 11-2013)
                  Taxation Division             Phone: (573) 751-8750    
                  P.O. Box 999                  TTY:  (800) 735-2966 Visit http://www.dor.mo.gov/business/withhold 
                  Jefferson City, MO 65108-0999 Fax: (573) 522-6816             for additional information.
                                                E-mail:  withholding@dor.mo.gov