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                                    State of Missouri                                                                                                                                                     Print           Reset
                                    John R. Ashcroft, Secretary of State 
                                    Corporations Division
                                    PO Box 778 / 600 W. Main St., Rm. 322
                                    Jefferson City, MO 65102 

                                                              Application for  Certificate of Withdrawal
                                                                    of a Foreign Nonprofit Corporation
                                      (Submit�with�filing�fee�of�$10.00�and�Certificate�of�Tax�Clearance�issued�by�the�Missouri�Department�of�Revenue) 

1. �The�Corporation’s�name�is ��������������������������������������������������������������������������������������������������������������Missouri�Charter�#:

����and�it�is�organized�and�existing�under�the�laws�of�

2. The�corporation�is�not�transacting�business�in�this�state,�and�it�surrenders�its�authority�to�transact�business�in�the�State�of�Missouri. 

3. The�corporation�revokes�the�authority�of�its�registered�agent�to�accept�service�on�its�behalf�and�appoints�the�Missouri�Secretary�of
   State�as�its�agent�for�service�of�process�in�any�proceeding�based�on�a�cause�of�action�arising�during�the�time�it�was�authorized�to
   do�business�in�the�State�of�Missouri. 

4. The�mailing�address�to�which�the�Secretary�of�State�may�mail�a�copy�of�any�service�of�process�is: 

������������������������������������Address �����������������������������������������������������������������������������������������������������������������������������������City,�State,�Zip 

5. The�corporation�will�notify�the�Secretary�of�State�of�any�future�changes�of�mailing�address. 

6. ��The �effective �date           � �of this �document � �is   the�date �is� �it   filed  � �by   the �Secretary � �of State � �of Missouri �unless            �future�a                       �date � �is otherwise �indicated: 

                                                           (Date�may�not�be�more�than�90�days�after�the�filing�date�in�this�Office)�

In�Affirmation�thereof,�the�facts�stated�above�are�true�and�correct:
(The �undersigned   �understands               �that �false �statements      �made         �in�this  �filing �are �subject �to�the   �penalties �provided                                       �under �Section �575.040, �RSMo) 

Authorized�Signature�of�Officer�or�Chairman�of�the�Board�����������������������������������������Printed�Name����������������������������������������������Title                                                 �Date 

Name�and�address�to�return�filed�document: 

Name: 

Address: 

City,�State,�and�Zip�Code: 
                                                                                                                                                                                                                Corp.�49�(01/2017) 

                                                                                                                                                                             Reset Form                Print Form

                                                                                                                                             Department Use Only 
                                                        Form         Missouri Department of Revenue                                          (MM/DD/YY) 
                                                        943          Request for Tax Clearance 

Missouri Tax I.D.                                                                                                                   Federal Employer 
Number                                                                                                                              I.D. Number 

Charter 
Number 
 1. Does this business have Missouri employees for which they are required to withhold Missouri taxes?                                                                                      r  Yes  r  No 
 2.  Do you pay contributions to the Division of Employment Security?                                                                 r  Yes  r  No  
    If yes, what is that account number? _______________________________ 
                                                         If there has been a change in the ownership of your business, you may need to contact Business Tax Registration at (573) 751-5860 to ensure 
                                                         your account is property registered. 
                                                           r   Corporation      r  Partnership     r  Sole Proprietorship 
    Ownership                                              r  Limited Liability Company    Taxed as:          r  Corporation   r  Partnership    r                      Sole Owner 
                                                         Name                                                                    Doing Business As Name (DBA) 
                                                         Mailing Address                                                         City                                             State          Zip Code 
                     Business
                                                        1.     I am completing the following transaction with the Missouri Secretary of State’s Office.                           It is not necessary to type hyphens or dashes.
                                                             r Reinstatement      r  Withdrawal or Termination  r  Merger —Date of Merger ___ ___ / ___ ___ / ___ ___ ___ ___ 
                                                          All tax types and the account with the Division of Employment Security will be reviewed and must be filed and paid in full. 
                                                        2.  I am completing the following transaction:     r           Selling Business Assets     r                    Financial Closing    r  MBE or WBE 
                                                            r   Missouri Quality Jobs    r  Other  ________________________________________________________________________________ 
                                                             All tax types and the account with the Division of Employment Security will be reviewed and must be filed and paid in full. 
                                                        3.  I require a sales or use tax Certificate of No Tax Due for the following:           Select all that apply. 
                                                             r  Business License        r Liquor License            r  Other (if not listed) _____________________________________________________ 
                     Reason(s) for Request
                                                        4.   I require a sales or use tax Vendor No Tax Due            to obtain or renew a contract with the state of Missouri. 
                                                             Contact person  ______________________________________________                  Phone Number   ( ___ ___ ___ ) ___ ___ ___ ___-               ___ ___ ___ 
                                                        If there has been a name change for this corporation, please provide prior name. 
                                                        _____________________________________________________________                                                   If individual income tax returns have been  
                                                        r  This corporation files consolidated corporation income tax returns in Missouri.                              previously filed in another state, please 
                                                             Parent Corporation Information  :                                                                          provide a list of the states and years filed.  Attach
                                                                                                                                                                        additional page(s) to this form if needed.
                                                              Missouri Tax Identification Number 
                                                                 |     |    |    |         |   | |                                                 Sole                  Your Social Security Number
                                          Corporations        Federal Employer Identification Number                                                                      |       |       |    |   |   |            | |        
                                                                |     |    |     |         |   | |        |                                             Proprietorships  Spouse’s Social Security Number
                                                        Missouri corporation franchise tax returns cannot be filed consolidated and must  
                                                        be filed by each corporation.                                                                                        |    |       |    |   |   |            | |        
                                                         All correspondence will be released to the person authorized below.  Release of this information to a third party (such as an accountant) at the request of the taxpayer  
                                                         does not give the third party authority to request further information from the Department. To obtain additional information or to represent the taxpayer before the  
                                                         Department, the taxpayer must execute a Power of Attorney designating the third party as its representative. 
                                                         Name of Person Authorized to Receive This Information               Title                                                        Phone Number 
                                                                                                                                                                                          ( _ _ _ ) _ _ _ - _ _ _ _ 
                                                         Address                                                             City                                                 State           Zip Code 
                                          Authorization 
                                                         E-mail Address of Authorized Person 

                                                        Under penalties of perjury, I declare that the above information and any attached supplement is true, complete, and correct   . 
                                                         Signature of Owner or Officer                                       Title                                                        Phone Number 
                                                                                                                                                                                       ( _ _ _ ) _ _ _ - _ _ _ _ 
    Signature                                            Printed Name of Owner or Officer                                                                                                 Please fax the results to 
                                                                                                                                                                                       ( _ _ _ ) _ _ _ - _ _ _ _ 
                                                                                                                                                                                                     Form 943 (Revised 12-2014)
Mail to:   Taxation Division                                                                         Phone: (573) 751-9268                                               
                                                               P.O. Box 3666                         Fax: (573) 522-1265                                                *14012010001*
                                                               Jefferson City, MO 65105-3666         E-mail:   taxclearance@dor.mo.gov                                                    14012010001 

                                                            Frequently Asked Questions 
 1.     What if I don’t know my Missouri tax identification number?                         No, the corporation franchise tax is imposed upon “every                       
          The Missouri tax identification number is assigned by the                         corporation organized under or subject to      Chapter 351, RSMo                .” 
        Missouri Department of Revenue  at  the time you  register  for                     Therefore, LLCs, which are organized under       Chapter 347, RSMo              , 
        the reporting of sales, use, withholding, corporation income,                       are not subject to franchise tax. 
        or corporation franchise tax.   If you have not registered your             
        business  or  need  to  check  on  the  status  of        a  registration,     8.     What are the reasons a corporation is dissolved? 
        please contact Business Tax Registration at (573) 751-5860.                           A corporation can be dissolved for failure to file the Annual Report,  
                                                                                            failure to file and or pay required taxes, failure to maintain                 
 2.     What is my federal employer identification number?                                  a registered agent, and practicing fraud against the state. 
          The Internal Revenue Service issues your federal employer         iden-
        tification number when you register to file federal taxes.           If you    9.     What are the consequences of being administratively dissolved                
        do not have this number, we will review the account based on the                    versus voluntarily dissolved? 
        information provided.                                                               If the corporation voluntarily dissolves, it indicates the  corporation  
                                                                                            requested the dissolution.  If it is administratively dissolved, the           
 3.       What is my corporation charter number or certificate of authority                 Secretary of State’s Office has dissolved the corporation.  If the  
        number?                                                                             corporation  is  administratively  dissolved,   it  could  have  difficulty 
          Your corporate charter number is issued to a Missouri corporation,                when bidding a job in the state, trying to obtain a loan, or when  
        limited liability company or limited partnership, by the Missouri                   completing a financial closing through a bank. The Secretary of                
        Secretary of State’s Office, authorizing your company to transact                   State’s website is:http://www.sos.mo.gov/  , and may be viewed for             
        business  in  the  State  of  Missouri.    The  certificate  of  authority          additional information, forms, and the current status of the                   
        number is issued by the Missouri Secretary of        State’s Office to              corporation. 
        foreign entities. Questions concerning these numbers should                 
        be directed to the Missouri Secretary of State’s Office at (573)             10.   Does this request have   to be signed by the owner or corporate                 
        751-4153.                                                                           officer? 
                                                                                              Yes, an officer or the owner must sign the request. 
  4.  I am  a foreign corporation.  Am I required to register with the              
        Missouri Secretary of State’s Office?                                        11.   Can I send my Secretary of State application with my tax                        
            If  you  are  a  corporation,  you  must  be  authorized  to  transact          clearance request form? 
        business in the State of Missouri with the Missouri                                   No, once you receive the clearance letter it is sent with all required 
        Secretary of State’s Office.  Some foreign corporations may                         information to the Secretary of State’s Office. 
        not be required to obtain a certificate of authority number in              
        Missouri.      If  your  corporation is  not  required, indicate so and      12.   Will the Secretary of State’s Office accept a faxed copy of the tax 
        the reason why. You may review           Section 351.572.2 RSMo      , for          clearance? 
        possible reasons a corporation may not be required to register.                       Yes, as long as it is within the allotted 60 day timeframe indicated 
                                                                                            on the clearance letter.  Because the letter is only valid for                 
  5.      Why do I have to file a franchise tax return if I am not a franchise?             60  days,  you  may  need  to  take  this  into  consideration  when           
          Franchise tax is a tax based on the amount of assets a corporation                completing the request for tax clearance and not request it too                
        has in or apportioned to the state of Missouri. It does not pertain to              soon. 
        being a franchise. 
                                                                                        If  you  have  questions  concerning  the  tax  clearance,     please  contact 
 6.       Are not-for-profit corporations subject to franchise tax?                  the Missouri Department of Revenue, Tax Clearance Unit at (573)                       
          No, pursuant to    Section 147.010, RSMo, not-for-profit corpora-          751-9268.  The fax number is (573) 522-1265. 
        tions are not subject to franchise tax.
                                                                                     If you have questions concerning reinstatements, please contact the                   
 7.  Are LLCs subject to franchise tax?                                              Missouri Secretary of State’s Office at (573) 751-4153 or toll free at                
                                                                                     (866) 223-6535. 
                                                                         Federal Privacy Notice 
  The Federal Privacy Act requires the Missouri Department of Revenue                and the Multistate Tax Commission (   Chapters 32     and  143,  RSMo).  In  
  (Department) to inform taxpayers of the Department’s legal authority for           addition, statutorily provided non-tax uses are:  (1) to provide information to 
  requesting identifying information, including social security numbers, and to      the Department of Higher Education with respect to applicants for financial 
  explain why the information is needed and how the information will be used.        assistance  under  Chapter  173,   RSMo   and  (2)   to  offset   refunds   against  
                                                                                     amounts due to a state agency by a person or entity (Chapter 143, RSMo).  
  Chapter 143 of the Missouri Revised Statutes authorizes the Department             Information furnished to other agencies or persons shall be used solely for 
  to request information necessary to carry out the tax laws of the state of         the purpose of administering tax laws or the specific laws administered by
  Missouri.  Federal law 42 U.S.C. Section 405 (c)(2)(C) authorizes the states       the person having the statutory right to obtain it as indicated above.  (For the
  to require taxpayers to provide social security numbers.                           Department’s authority to prescribe forms and to require furnishing of social 
  The Department uses your social security number to identify you and                security numbers, see Chapters 135, 143, and 144, RSMo.) 
  process your tax returns and other documents, to determine and collect the         You are required to provide your social security number on your tax return.  
  correct amount of tax, to ensure you are complying with the tax laws, and to       Failure to provide your social security number or providing a false social 
  exchange tax information with the Internal Revenue Service, other states,          security number may result in criminal action against you. 

                                                      *14000000001* 
                                                                            14000000001                                                      Form 943 (Revised 12-2014)