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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 Foreign Corporation
                     (Submit�with�filing�fee�of�$25.00�and�Certificate�of�Tax�Clearance�issued�from�the�Missouri�Department�of�Revenue) 

The�undersigned�corporation,�for�the�purpose�of�withdrawing�from�the�State�of�Missouri�hereby�executes�the�following�document: 

1.� The�name�of�the�Corporation�is��                                                                                                                                  Missouri�Charter�#:

����and�is�organized�and�exists�under�the�laws�of 

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

   B. The�corporation�revokes�the�authority�of�its�registered�agent�in�Missouri�to�accept�service�of�process�and�consents�that�service�of
      process�in�any�suit,�action,�or�proceeding�based�upon�any�cause�of�action�arising�in�Missouri�during�the�time�the�corporation�was
      licensed�to�transact�business�in�Missouri�may�thereafter�be�made�on�the�corporation�by�service�on�the�Secretary�of�State�of 
      Missouri. 

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

                     Address                                                                                                                                 City/State/Zip 

   D. The �corporation �will �notify �the �Secretary � �of State � �of Missouri � �of                                                  any �future �change � �of mailing �address �for   period� �a  � �of five �years. 

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                                                            Printed�Name                                                                                Title                          Date 

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

Name: 

Address: 

City,�State,�and�Zip�Code: 
                                                                                                                                                                                                     Corp.�48�(01/2017)

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

                                                                                                             **DO NOT enter hyphens or dashes**
Missouri Tax Identification Number                                        Federal Employer Identification Number (FEIN)                                                   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, list account number  _______________

                                   Name                                                                                              Doing Business As Name (DBA)
                                   Mailing Address                                                                                   City                                 State              ZIP Code
        Business
                                   Select Ownership Type: Choose One
                                     r Corporation     r Partnership     r Sole Proprietorship
                Ownership            Limited Liability Company that is taxed as:                             r Corporation   r Partnership      r Sole Owner

                                   If there has been a name change for this corporation, please provide prior name.                                                       If individual income tax returns have been 
                                   _____________________________________________________________                                                                          previously filed in another state, please 
                                                                                                                                                                          provide a list of the states and years filed.  
                                   r This corporation files consolidated corporation income tax returns in Missouri.                                                      Attach additional page(s) to this form if needed.
                                         Parent Corporation Information: 
                                                                                                                                                  Sole                    Your Social Security Number
                                       Missouri Tax Identification Number 
 Corporations                                                                                                                                                                   |        |        |        |        |        |        |        |        
                                              |        |        |        |        |        |        |        
                                        Federal Employer Identification Number                                                                            Proprietorships Spouse’s Social Security Number
                                              |        |        |        |        |        |        |        |                                                                  |        |        |        |        |        |        |        |        

                                     Select Reason for Request: Choose One 
                                     1.    I am completing the following transaction with the Missouri Secretary of State’s Office. 
                                         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 or Financial Closing        r Dept. of Economic Development
                                         r Office of Administration Contract Bid greater than $1,000,000 (Page 2 is required.)  r Linked Deposit  
                                       r Other    __________________________________________________________________________________________
                Reason for Request      All tax types and the account with the Division of Employment Security will be reviewed and must be filed and paid in full.
                                     3.  r I require a Vendor No Tax Due   to obtain or renew a contract with the state of Missouri.Page(                                               2 is required.) 

                                   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 email results to:                                          

                                                                                                                                                                                             Form 943 (Revised 12-2021)
Mail to:   Taxation Division                                                                                           E-mail:  taxclearance@dor.mo.gov 
                                        P.O. Box 3666                                                                  Ever served on active duty in the United States Armed Forces?  
                                        Jefferson City, MO 65105-3666                                                  If yes, visit dor.mo.gov/military/ to see the services and benefits we offer to all eligible 
Phone:                                   (573) 751-9268                                                                military individuals. A list of all state agency resources and benefits can be found at 
Fax:                                     (573) 522-1265                                                                veteranbenefits.mo.gov/state-benefits/.

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Complete this page and attach to form 943 if Reason for Request on page 1 is for a Vendor No Tax Due or Office of Administration contract
or bid greater than $1,000,000. All applicable identification numbers must be completed on page 1 in order to process your request.

1. I am requesting a Vendor No Tax Due for a .................................... r Bid r Contract

2. Is the bid or contract for a ................................................. r Individual r Business

Reason for Request

1. Name of state agency or university that the bid or contract is with. ___________________________________________________________
_______________________________________________________________________________________________________________

2. What service(s) or item(s) will be supplied in the bid or contract? ____________________________________________________________

3. Does the business or individual make taxable sales to Missouri customers? .................................. r Yes r No
4. Does the business or individual have any affiliates (any person or entity that is controlled or under common
Information control with the vendor) in the state of Missouri? ....................................................... r Yes r No
If yes, please list the FEIN(s) and Missouri Tax Identification Number(s). Attach a second sheet if needed. ___________________________
_______________________________________________________________________________________________________________

5. Do any of the affiliates make taxable sales? .................................................... r Yes r No r N/A

Comments

Form 943 (Revised 12-2021)

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Frequently Asked Questions
1. What if I don’t know my Missouri tax identification number? 6. What are the consequences of being administratively dissolved
The Missouri tax identification number is assigned by the Missouri versus voluntarily dissolved?
Department of Revenue at the time you register for the reporting If the corporation voluntarily dissolves, it indicates the corporation
of sales, use, withholding, corporation income, or corporation requested the dissolution. If it is administratively dissolved, the
franchise tax. If you have not registered your business or need to Secretary of State’s Office has dissolved the corporation. If the
check on the status of a registration, please contact Business Tax corporation is administratively dissolved, it could have difficulty
Registration at (573) 751-5860. If you do not have a Missouri Tax when bidding a job in the state, trying to obtain a loan, or when
Idenification number leave blank. completing a financial closing through a bank. The Secretary of
State’s website is: www.sos.mo.gov, and may be viewed for additional
2. What is my federal employer identification number? information, forms, and the current status of the corporation.
The Internal Revenue Service issues your federal em ployer
identification number when you register to file federal taxes. If you 7. Does this request have to be signed by the owner or corporate
do not have this number, we will review the account based on the officer?
information provided. Yes, an officer or the owner must sign the request.

3. What is my corporation charter number or certificate of authority 8. Is there a fee to request a tax clearance?
number?
Your corporate charter number is issued to a Missouri corporation, No. There is no fee to submit a Request for Tax Clearance.
limited liability company or limited partnership, by the Missouri
9. Can I send my Secretary of State application with my tax
Secretary of State’s Office, authorizing your company to transact clearance request form?
business in the State of Missouri. The certificate of authority
number is issued by the Missouri Secretary of State’s Office to No, once you receive the clearance letter it is sent with all required
foreign entities. Questions concerning these numbers should information to the Secretary of State’s Office.
be directed to the Missouri Secretary of State’s Office at (573)
10. Will the Secretary of State’s Office accept a faxed copy of the tax
751-4153. clearance?
4. I am a foreign corporation. Am I required to register with the Yes, as long as it is within the allotted 60 day timeframe indicated
Missouri Secretary of State’s Office? on the clearance letter. Because the letter is only valid for 60 days,
you may need to take this into consideration when completing the
If you are a corporation, you must be authorized to transact business request for tax clearance and not request it too soon.
in the State of Missouri with the Missouri Secretary of State’s Office.
Some foreign corporations may not be required to obtain a certificate
of authority number in Missouri. If your corporation is not required, If you are requesting a No Tax Due use No Tax Due Request (Form 5522).
indicate so and the reason why. You may review Section 351.572.2,
RSMo, for possible reasons a corporation may not be required to If you have questions concerning the tax clearance, please contact the
register. Missouri Department of Revenue, Tax Clearance Unit at (573) 751-9268.
The fax number is (573) 522-1265.
5. What are the reasons a corporation is dissolved?
If you have questions concerning reinstatements, please contact the
A corporation can be dissolved for failure to file the Annual Report, Missouri Secretary of State’s Office at (573) 751-4153 or toll free at
failure to file and or pay required taxes, failure to maintain a (866) 223-6535.
registered agent, and practicing fraud against the state.

Federal Privacy Notice
The Federal Privacy Act requires the Missouri Department of Revenue states, and the Multistate Tax Commission(Chapter 32and 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 You are required to provide your social security number on your tax return.
the correct amount of tax, to ensure you are complying with the tax laws, Failure to provide your social security number or providing a false social
and to exchange tax information with the Internal Revenue Service, other security number may result in criminal action against you.

Form 943 (Revised 12-2021)

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