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0 0 0 4 4 4 4 0 Missouri Department of Revenue Department Use Only
0 0 0 5 5 5 5 0 Form Safe at Home - Request for Address (MM/DD/YY)
0 0 0 6 6 6 6 0 Confidentality of Tax Records
0 0 0 7 7 7 7 0 5143
0 0 0 8 8 8 8 0
0 0 0 9 9 9 9 0
1 1 1 0 0 0 0 1 Missouri Tax I.D. Social Security
1 1 1 1 1 1 1 1 Number Number
1 1 1 2 2 2 2 1
1 1 1 3 3 3 3 1 This form must be completed and returned to the Missouri Department of Revenue, Taxation Division, to initiate or update a “Safe at
1 1 1 4 4 4 4 1 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.
1 1 1 5 5 5 5 1
1 1 1 6 6 6 6 1 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
1 1 1 7 7 7 7 1 will be used only on the tax types you designate below.
1 1 1 8 8 8 8 1
1 1 1 9 9 9 9 1 Taxpayer Name (last, first, middle)
2 2 2 0 0 0 0 2
2 2 2 1 1 1 1 2
2 2 2 2 2 2 2 2 Previous Address City State ZIP Code
Individual Income Tax
2 2 2 3 3 3 3 2
2 2 2 4 4 4 4 2
2 2 2 5 5 5 5 2 Business Name
2 2 2 6 6 6 6 2
2 2 2 7 7 7 7 2 Tax
2 2 2 8 8 8 8 2 Business Previous Address City State ZIP Code
2 2 2 9 9 9 9 2
3 3 3 0 0 0 0 3
3 3 3 1 1 1 1 3 Safe at Home Identification Number _____ _____ _____ _____
3 3 3 2 2 2 2 3
3 3 3 3 3 3 3 3 Select the box or boxes below for the tax programs that affect you.
3 3 3 4 4 4 4 3 r Individual Income Tax r Sales Tax
3 3 3 5 5 5 5 3
r Property Tax Credit r Vendor’s Use Tax
3 3 3 6 6 6 6 3
3 3 3 7 7 7 7 3 r Fiduciary Tax r Consumer’s Use Tax
3 3 3 8 8 8 8 3 r Employer Withholding Tax r Corporation Income Tax
3 3 3 9 9 9 9 3
4 4 4 0 0 0 0 4 Tax Records r Cigarette or Other Tobacco Products Tax r Corporation Franchise Tax
4 4 4 1 1 1 1 4 r Motor Fuel Tax r Tire and Battery Fee
4 4 4 2 2 2 2 4 r Other: (Please Specify) _________________________________________________
4 4 4 3 3 3 3 4
4 4 4 4 4 4 4 4 _________________________________________________
4 4 4 5 5 5 5 4
4 4 4 6 6 6 6 4 I understand the “Safe at Home” address will be used as my mailing address for the Department to send tax related mail for the
4 4 4 7 7 7 7 4 taxes noted above. This address only affects the mailing address of my residence and does not affect any other addresses. This
4 4 4 8 8 8 8 4 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
4 4 4 9 9 9 9 4 filed on my behalf, with a “Non-Safe at Home” address, it constitutes notification to the Taxation Division that I am no longer
4 4 4 0 0 0 0 4 in the “Safe at Home” program and the Taxation Division will no longer use the “Safe at Home” address as my mail-to address.
5 5 5 1 1 1 1 5 Signature I also confirm that I have been certified as an authorized “Safe at Home” program participant approved by the Secretary of State.
5 5 5 2 2 2 2 5
5 5 5 3 3 3 3 5 Signature Date (MM/DD/YYYY)
5 5 5 4 4 4 4 5 __ __ /__ __ /__ __ __ __
5 5 5 5 5 5 5 5
5 5 5 6 6 6 6 5 A copy of your “Safe at Home” authorization card must be attached with this form.
5 5 5 7 7 7 7 5 Form 5143 (Revised 09-2014)
5 5 5 8 8 8 8 5 Mail to: Taxation Division Phone: (573) 751-3505 Visit
5 5 5 9 9 9 9 5 P.O. Box 2200 TTY: (800) 735-2966 http://www.sos.mo.gov/business/SafeAtHome/
5 5 5 0 0 0 0 5 Jefferson City, MO 65105-2200 E-mail: income@dor.mo.gov for additional information.
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14309010001
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