Department Use Only
                   Form                                                            (MM/DD/YY)
                        Withholding Tax Job Training Program
                  4096  Authorization For Release of Confidential Information

Missouri Tax I.D. 
Number

 I,                                                                                                                ,  the  undersigned  principal,  who  is  an  officer  authorized 
 to  sign  for  the  corporation,  or  is  the  owner  of  the  business,  identified  by  Missouri  Tax  Identification  Number 
 as indicated above, and Federal Identification Number                 –                                                    ,  do  hereby 
 authorize and request the Department of Revenue, State of Missouri, to release the confidential employer withholding 
 tax credit training information as reported to the Department pertaining to the above specified account for all tax 
 periods relating to participation in:

  r  New Jobs Training Program

  r  Job Retention Training Program

 This authorization shall be effective this date and until all of the costs associated with my Job Training Program have 
 been paid in full.

 I, specifically authorize release of such information to the Department of Economic Development, Division of 
 Workforce Development.

 I, hereby release the Director of Revenue and Department personnel from any and all liability pursuant to unauthorized 
 disclosures of confidential tax information resulting from release of subject information under Section 32.057, RSMo, 
 or any other applicable confidentiality statute.

                  Under penalties of perjury, I declare that the above information and any attached supplement is true, complete, and 
                  correct. If prepared by a person other than the owner, this declaration is based on all information of which he has 
                  any knowledge.
                  I also declare that I have the authority to make this request on behalf of __________________________________
                  _____________________________________________________________________________ (business name).
         Signature
                  Owner or Officer Signature                               Owner or Officer Printed Name

                  Title                                      Phone Number                               Date (MM/DD/YYYY)
                                                             (___ ___ ___) ___ ___ ___- ___ ___ ___ ___ ___ ___ / ___ ___ / ___ ___ ___ ___
                                                                                                                       Form 4096 (Revised 12-2014)
Mail to:  Taxation Division                           Phone: (573) 751-8750     Visit http://dor.mo.gov/business/withhold/
                        P.O. Box 3375                 TTY: (800) 735-2966                   for additional information.
                        Jefferson City, MO 65105-3375 Fax: (573) 522-6816
                                                      E-mail:  withholdingproject@dor.mo.gov 

                                                      *14209010001*
                                                                  14209010001