Form 2643A – Fill Out and Use This PDF

<![endif]>Information

4. Owner Name (Enter Corporation, LLC or Partnership Name, if applicable)

Address

E-mail Address

<![endif]>Owner

City

State

ZIP Code

County

If an individual is listed as the owner, you must also provide the following:

Social Security Number

Date of Birth (MM/DD/YYYY)

Telephone Number

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(___ ___ ___)___ ___ ___-___ ___ ___ ___

5. Ownership Type

r Sole Proprietor              r Partnership              r Government              r Trust

All ownership types listed below, unless specifically exempted, are required to be registered with the Missouri Secretary of State’s Office (register

at sos.mo.gov or call (866) 223-6535). Your application will not be complete without providing the charter number issued to you by their office.

<![endif]>Type

r Limited Partnership - LP Number __________________________________

r Not Required to register with Missouri Secretary

r Limited Liability Partnership - LLP Number ___________________________

of State

<![endif]>Ownership

r Limited Liability Company - LLC Number ____________________________

r Other

Taxed as a   r Disregarded Entity        r Partnership        r Corporation

r Missouri Corporation - Missouri Charter No. _________________________

Date Incorporated (MM/DD/YYYY)

___ ___ / ___ ___ / ___ ___ ___ ___

r Non-Missouri Corporation - Missouri Charter No. ______________________

State of Incorporation _________________________ Date Registered in Missouri (MM/DD/YYYY)

___ ___ / ___ ___ / ___ ___ ___ ___

6. Is there a previous owner or operator for the business?    r Yes*     r No    *If yes, the following section must be completed.

<![endif]>Information

Select any of the following that you purchased from the previous owner:

r Inventory

r Fixtures r Equipment

r Real Estate

r Other __________________________________________________________________________________________________________

_____________________________________________________________________

<![endif]>Owner

Purchase Price

Name of Previous Owner or Operator

Missouri Tax Identification Number

<![endif]>Previous

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Physical Location of Previous Business

City

State

ZIP Code

Address of Previous Business

City

State

ZIP Code

<![endif]>Tax

29. Is this corporation registered with the Internal Revenue Service as a

r Regular or Close Corporation

r Sub Chapter S Corporation

<![endif]>Income

30. Corporation Tax Begin Date in Missouri (MM/DD/YYYY)

Corporation Taxable Year End (MM/DD)

<![endif]>Corporate

___ ___/___ ___/___ ___ ___ ___

___ ___/___ ___

tax is expected to be at least $250, or 6.25% of the Missouri taxable income, check the “Yes” box

r Yes

r No

31. Will the corporation be required to make quarterly estimated Missouri income tax payments? If the Missouri estimated

32. Missouri Withholding Begin Date (MM/DD/YYYY)

How many of your employees will work in Missouri?

___ ___/___ ___/___ ___ ___ ___

33. Estimated employer withholding tax liability (select one). Your selection will determine your return filing frequency.

Estimated monthly gross wages _____________________ X 5.4% = __________________________

r Annually (less than $100 withholding tax per quarter)

r Monthly ($500 to $9,000 withholding tax per month)

r Quarterly ($100 withholding tax per quarter to $499

r Quarter-Monthly (weekly) (over $9,000 withholding tax per month; required

per month)

to pay electronically)

34. Does a parent company file withholding tax reports and receive full compensation for timely filed returns?

r Yes

r No

35. If you do not pay wages year round, please check the months that you do pay wages.

r January r February r March r April r May r June r July r August r September r October r November r December

Withholding Tax Courtesy Mailing Address (a copy of all withholding tax delinquent notices will be mailed to this address)

<![endif]>Tax

36. Business Name (DBA name)

<![endif]>Withholding

Street, Route or P.O. Box

City

(___ ___ ___)___ ___ ___-___ ___ ___ ___

County

State

ZIP Code

Business Telephone Number

<![endif]>Employer

Transient Employer

37.

Are you a transient employer?

r Yes

r No

An employer not domiciled in Missouri and temporarily transacting business in Missouri for less than 24 consecutive months is defined as a transient employer.

(Example: contractor, temporary staffing agency, etc.). For additional information, contact the Department at businesstaxregister@dor.mo.gov or call

(573) 751-0459. If you have indicated that you are a transient employer, you must complete the entire Employer Withholding Tax Section above.

A transient employer must submit the following with this application:

Missouri Employment Security Account Number

• A completed insurance certification slip indicating Missouri as a covered state for worker’s compensation

• Missouri Employment Security Account number, if hiring a Missouri resident: (first seven digits required)

• Your Missouri Certificate of Authority Number issued by the corporate division of the Missouri Secretary of State’s Office

• A Transient Employer Bond not less than $5,000

Calculate your transient employer bond:

A. Missouri withholding tax

Monthly gross wages _______________________

X 5.4% = _____________________ X 3 = ____________________________ (a)

B. Missouri unemployment tax

Average # of workers __________ X $7,000 = __________________ X 3.38% __________________ / 4 = ___________________ (b)

(a) ___________________________ + (b) ___________________ = ______________________________ (amount of bond - minimum $5,000)

Visit dor.mo.gov/forms/?formName=&category=13&year=99 for bond forms.

Type of bond r Cash Bond (Form 332) r Certificate of Deposit (Form 4172) r Irrevocable Letter of Credit (Form 2879) r Surety Bond (Form 331)

Comments:

Under penalties of perjury, I declare that the above information and any attached supplement is true, complete, and correct. This application must be signed by the owner, if the business

is a sole proprietorship, or by an individual listed in the Officer, Partners, or Members section of this application. The signing party is acknowledging that they have direct supervision or

control over tax matters.

<![endif]>Signature

Signature

Title

Date (MM/DD/YYYY)

___ ___ / ___ ___ / ___ ___

___ ___

Typed or Printed Name

E-mail Address

Confidentiality of Tax Records

Missouri Statute 32.057, RSMo, states that all tax records and information maintained by the Missouri Department of Revenue 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 the Department with a power of attorney to grant the authority to release confidential information to them. Visit dor.mo.gov/forms to obtain a Power of

Attorney (Form 2827).

Mail to: Taxation Division

Form 2643A (Revised 08-2021)

P.O. Box 357

Visit dor.mo.gov/register-business/ for additional information.

Jefferson City, MO 65105-0357

Ever served on active duty in the United States Armed Forces?

Phone: (573) 751-5860

If yes, visit dor.mo.gov/military/ to see the services and benefits we offer to all eligible

military individuals. A list of all state agency resources and benefits can be found at

Fax: (573) 522-1722

veteranbenefits.mo.gov/state-benefits/. *14606040001*

E-mail: businesstaxregister@dor.mo.gov

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