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                       Missouri Department of Revenue
                  Form Withholding Affidavit  
 MO W-4C               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.

                  Name                                                                                                                                                        Missouri Tax Identification Number
                                                                                               |        |        |        |        |        |        |        
                  Street Address                                                       City                                                                  State          ZIP Code
        Employer

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

 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.

 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                                                                             

        Signature Printed Name                                                      Date (MM/DD/YYYY)
                                                                                    __ __ /__ __ /__ __ __ __

                                                                                                                                                                     Form MO W-4C  (Revised 11-2013)
Mail to:               Taxation Division             Phone: (573) 751-8750              
                       P.O. Box 999                  TDD:  (800) 735-2966    Visit http://www.dor.mo.gov/business/withhold 
                       Jefferson City, MO 65108-0999 Fax: (573) 522-6816            for additional information.