Missouri Development Finance Board                                                                            MISSOURI FORM 
              VERIFICATION OF CONTRIBUTION TO THE 
              INFRASTRUCTURE DEVELOPMENT FUND                                                                               100 
                                                                                                                     RSMo. Section 100.286.6 

A Missouri Form 100 must be used when making a contribution to an approved project.  Contributions can be in the form of a check, wire 
transfer, or marketable securities.  Checks must be payable to the “Missouri Development Finance Board” and not to the project title.  
Application must be approved prior to due date of tax return.  If more than one individual is listed as the Contributor, the Social 
Security Number and signature of all individuals must be included. 

CONTRIBUTOR / CONTRIBUTION 
Individual’s Name(s) or Name of Business Making the Contribution 

Attention:                                                                                 Title 

Address                                                                               City                                  State ZIP Code 

Federal ID No. (FEIN)                                             Missouri Tax ID No.             Social Security Number(s) 

Telephone Number                                                  Fax Number                      E-mail

Amount of the Contribution                                        Date the Contribution was Made Project Name 
(In the case of marketable securities, the amount of contribution 
equals the net liquidated proceeds.) 

$ 
Issued for Calendar Year                                          or Tax Year Beginning                       Ending 

TAXPAYER TYPE (check one) 
  Corporation                        Fiduciary                    Individual Proprietorship       Partnership S-Corporation       Individual 

If the taxpayer is a Corporation, Fiduciary, Partnership, or S-Corporation, or other business entity, a Certificate of Alien Employment must 
be included with the contribution. The Certificate of Alien Employment Form can be found at https://mdfb.org/ 
VERIFICATION OF CONTRIBUTION 
  •     I certify that I am an authorized representative of the Contributor and as such am authorized to make the statement of
        affirmation contained herein.
  •     I certify under penalties of perjury, that a contribution was made to the Infrastructure Development Fund by the subject
        taxpayer on the date and in the amount indicated above.
Signature(s) of Contributor 

► 
RETURN COMPLETED                                                  Mailing Address                 UPS or Fed-Ex Overnight Address 
FORM TO:                              Missouri Development Finance Board                          Missouri Development Finance Board 
                                                                  P.O. Box 567                                200 Madison Street, Suite 1000 
                                                                  Jefferson City, Missouri  65102             Jefferson City, Missouri  65101 

TO BE COMPLETED BY THE MISSOURI DEVELOPMENT FINANCE BOARD 
                                                                     Initials/date                            Notes 
Initial verification of Contribution: 

Accounting verification of Contribution: 

Approval of Tax Credit Certificate: 

                                                                                                              Revised January 2022