Reset Form         Print Form

                                                        Missouri Department of Revenue                            Department Use Only
                                              Form      Safe at Home - Request for Address                        (MM/DD/YY)
                        5143                            Confidentality of Tax Records

Missouri Tax I.D.                                                                                     Social Security
Number                                                                                                Number
This form must be completed and returned to the Missouri Department of Revenue, Taxation Division, to initiate or update a “Safe at 
Home” address for taxes administered by the Taxation Division. To change any other addresses to a “Safe at Home” address  please contact the 
appropriate area or government agency.  
Please  complete  the  information  below  and  attach  a  copy  of  your  “Safe  at  Home”  authorization  card  issued  by  the  Secretary  of  State.  This 
information will be used to update your mail-to address in the Taxation Division’s records with your “Safe at Home” address. Your “Safe at Home” address 
will be used only on the tax types you designate below.   

                                              Taxpayer Name (last, first, middle)

                                              Previous Address                                         City                                     State                           ZIP Code
            Individual              Income Tax

                                              Business Name

                                     Tax
            Business                          Previous Address                                         City                                     State                           ZIP Code

                                                               Safe at Home Identification Number   _____   _____   _____   _____

                                               Select the box or boxes below for the tax programs that affect you.
                                                        r Individual Income Tax                        r Sales Tax
                                                        r Property Tax Credit                          r Vendor’s Use Tax
                                                        r Fiduciary Tax                                r Consumer’s Use Tax
                                                        r Employer Withholding Tax                     r Corporation Income Tax                  
                        Tax Records                     r Cigarette or Other Tobacco Products Tax      r Corporation Franchise Tax
                                                        r Motor Fuel Tax                               r Tire and Battery Fee                    
                                                        r Other: (Please Specify)  _________________________________________________
                                                                                  _________________________________________________

                                              I understand the “Safe at Home” address will be used as my mailing address for the Department to send tax related mail for the  
                                              taxes noted above.  This address only affects the mailing address of my residence and does not affect any other addresses. This  
                                              address will be used until I notify the Department of an address change or the Secretary of State rejects my mail because I am  
                                              no  longer  a  qualified  participant  of  the  “Safe  at  Home”  program.  I  understand  if  I  file  any  returns  or  other  documents  or  any  are  
                                              filed  on  my  behalf,  with  a  “Non-Safe  at  Home”  address,  it  constitutes  notification  to  the  Taxation  Division  that  I  am  no  longer  
                                              in  the  “Safe  at Home”  program  and  the  Taxation  Division  will  no  longer  use  the  “Safe  at  Home”  address  as  my  mail-to  address.  
                        Signature             I also confirm that I have been certified as an authorized “Safe at Home” program participant approved by the Secretary of State. 
                                              Signature                                                                       Date (MM/DD/YYYY)

                                                                                                                              __ __ /__ __ /__ __ __ __
                                                               A copy of your “Safe at Home” authorization card must be attached with this form.
                                                                                                                                                Form 5143 (Revised 09-2014)
Mail to:  Taxation Division                                                      Phone: (573) 751-3505                                Visit  
                                                P.O. Box 2200                    TTY:  (800) 735-2966                http://www.sos.mo.gov/business/SafeAtHome/
                                                Jefferson City, MO 65105-2200    E-mail: income@dor.mo.gov                  for additional information.

                                                                                 *14309010001*
                                                                                           14309010001