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       State of Missouri 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:

                                    Addr                                                                                                                                   ess                                                                  City, State, Zip
                                                                                                                                                                                                                                                       
5.The corporation will notify the Secretary of State of any future changes of mailing address.
                                                                                                                                                                                                                                                                                    
6    .TheeffectivedateofthisdocumentisthedateitisfiledbytheSecretaryofStateofMissouriunlessafuturedateisotherwiseindicated:                                                                                                                                                                                 

                                                                                                                                                                               (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 undersignedunderstandsthatfalsestatementsmadeinthisfilingaresubjecttothepenaltiesprovidedunderSection575.040,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                     
        I  f 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)