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Record Storage Address (Do not use P.O. Box or Rural Route)
Street Address (Do not use P.O. Box or Rural Route)
City State ZIP Code County
Record Storage
Name (Last, First, Middle Initial) Title Social Security Number Birthdate (MM/DD/YYYY)
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Street Address City State ZIP Code
Officers Name (Last, First, Middle Initial) Title Social Security Number Birthdate (MM/DD/YYYY)
| | | | | | | | ___ ___ / ___ ___ / ___ ___ ___ ___
Street Address City State ZIP Code
Organization or Agency
In one or two brief statements, summarize the primary organizational purpose and the main activities. Explain the intended use of the exemption
letter.
Description of Organization
Under penalties of perjury, I declare that the above information and any attached supplement is true, complete, and correct; that the present
nature, purpose and activities of the above-named organization or agency are the same as they were when the attached documents were issued
and will continue to remain the same; that I will remain knowledgeable of the statutes and regulations governing sales or use tax exemptions and
that I will immediately notify the Department of any change in circumstances which could reasonably lead me to believe that the above-named
organization or agency would no longer qualify as exempt, either because of a change in the law or because of a material change in the
organization’s or agency’s nature, purpose, or activities.
It is understood that any misrepresentation contained herein or failure on my part to fulfill the promises entered into here will result in the
immediate revocation of any exemption letter issued to this organization or agency.
An officer, member, or responsible person must sign the application. If a power of attorney signs the application, you must include a Power of
Attorney (Form 2827) signed by an officer, member, or responsible person listed on the application.
Signature Signature of Officer or Responsible Person Title
Printed Name E-mail Address
Social Security Number Date of Birth (MM/DD/YYYY) Date (MM/DD/YYYY)
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Missouri Statute 32.057, RSMo, states that all tax records and information maintained by the Department are confidential. The tax information
can only be given to the owner, partner, member, or officer who is listed with us as such. If you wish to give an employee, attorney, or
accountant access to your tax information, you must supply us with a power of attorney giving us the authority to release confidential information
to them.
Records If your officers, members, or responsible persons change, you must update your registration with the Department by completing a Registration or
Exemption Change Request (Form 126), before we can release tax information to those new officers, members, or responsible persons.
Confidentiality of Tax
Mail to: Taxation Division E-mail: salestaxexemptions@dor.mo.gov Form 1746 (Revised 11-2019)
P.O. Box 358 Visit dor.mo.gov/taxation/business/tax-types/sales-use/ for additional information.
Jefferson City, MO 65105-0358
Ever served on active duty in the United States Armed Forces?
Phone: (573) 751-2836 If yes, visit dor.mo.gov/military/ to see the services and benefits we offer to all eligible
Fax: (573) 522-1666 military individuals. A list of all state agency resources and benefits can be found at
TTY: (800) 735-2966 veteranbenefits.mo.gov/state-benefits/.
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