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                                                                                                                                   Department Use Only
                                           Form                                                                                    (MM/DD/YY)
                                                                 Application For Direct Pay Authorization
4098

Missouri Tax I.D.                                                                                                       Federal Employer
Number                                                                                                                  I.D. Number

This application is to be used for applying for or renewing the direct pay authorization pursuant to                                                   Section 144.190.6, RSMo. This 
authorization, if issued, is valid for five years.
                                                                                                                New Application                Renewal 
                                                                       Type of application (select one):                r                      r

                                                       Business Name (attach list if necessary for additional locations)

                                                       Physical Address (Do not use PO Box or Rural Route Number)                              County                            

                                                       City                                                                                    State         ZIP Code

              Business                     Information Business Telephone Number                       E-mail Address
                                                       ( ___ ___ ___ ) - ___ ___ ___ - ___ ___ ___ ___
                                                       Mailing Address                                City                                     State    ZIP Code

                                                       Owner Name (Enter Corporation or LLC Name, if applicable)

                                                       Address                                                                                 County                            
       Owner  
                                           Information City                                                                                    State    ZIP Code                                        

                                                       List business locations for which you are requesting direct pay authorization (attach a supplemental list if necessary).
                                                       Street Address - Do Not Use PO Box or Rural Route                                       County

                                                       City                                                                                    State         ZIP Code                                            

                                                       Is this business located inside the city limits of any city or municipality in Missouri?
                                                       r No      r Yes - Specify the city:

                                                       Is this business located inside a district(s)?  For example, ambulance, fire, tourism, community, or transportation development.
                                                       r No      r Yes - Specify the district name(s):

                                                       Street Address - Do Not Use PO Box or Rural Route                                       County

                        Business Locations             City                                                                                    State         ZIP Code                                            

                                                       Is this business located inside the city limits of any city or municipality in Missouri?
                                                       r No      r Yes - Specify the city:
                                                       Is this business located inside a district(s)?  For example, ambulance, fire, tourism, community, or transportation development.
                                                       r No      r Yes - Specify the district name(s):

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                                                        Street Address - Do Not Use PO Box or Rural Route                                                                             County

                                                        City                                                                                                                          State         ZIP Code                           

                                                        Is this business located inside the city limits of any city or municipality in Missouri?
                                                        r No      r Yes - Specify the city:
                                                        Is this business located inside a district(s)?  For example, ambulance, fire, tourism, community, or transportation development.
                                                        r No      r Yes - Specify the district name(s):

                                                        Street Address - Do Not Use PO Box or Rural Route                                                                             County

                                                        City                                                                                                                          State         ZIP Code                           

                                                        Is this business located inside the city limits of any city or municipality in Missouri?
                                                        r No      r Yes - Specify the city:

                                                        Is this business located inside a district(s)?  For example, ambulance, fire, tourism, community, or transportation development.
                                                        r No      r Yes - Specify the district name(s):
                            Business Locations Continued
                                                        Street Address - Do Not Use PO Box or Rural Route                                                                             County

                                                        City                                                                                                                          State         ZIP Code                           

                                                        Is this business located inside the city limits of any city or municipality in Missouri?
                                                        r No      r Yes - Specify the city:
                                                        Is this business located inside a district(s)?  For example, ambulance, fire, tourism, community, or transportation development.
                                                        r No      r Yes - Specify the district name(s):

                                                        To verify if the business is located inside the city limits of any city or municipality visit mytax.mo.gov/rptp/portal/home/business/
                                                        salesUseTaxRateInformation/.

Sales Tax Rule 12 CSR 10-104.040 provides in part that records must be submitted to demonstrate that the business or corporation annually 
purchases non-resalable items in excess of $750,000.
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 us with a power of attorney giving us the 
authority to release confidential information to them.

                                                        Under penalties of perjury, I declare that the above information and any attached supplement is true, complete, and correct. The application 
                                                        must be signed by the owner, if the business is a sole ownership; partner, if the business is a partnership; reported officer, if the business is a 
                                                        corporation or by a member, if the business is an L.L.C. as reported on this application.
                                                        Signature of Officer or Responsible Person                                                    Title    

 Signature                                              Printed Name                                                                                                   E-mail Address 

                                                        Social Security Number                                Date of Birth (MM/DD/YYYY)                                              Date (MM/DD/YYYY)
                                                              |        |        |        |        |        |        |        |    ___ ___ / ___ ___ / ___ ___ ___ ___                 ___ ___ / ___ ___ / ___ ___ ___ ___
                                                                                                                                                                                                       Form 4098 (Revised 11-2019)
Mail to:  Taxation Division                                                                                                       E-mail:  salestaxexemptions@dor.mo.gov
                                                           P.O. Box 358                                                           Visit dor.mo.gov/taxation/business/tax-types/sales-use/ for additional information.
                                                           Jefferson City, MO 65105-0358

Phone:                                                     (573) 751-2836
Fax:                                                       (573) 522-1666 
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TTY:                                                       (800) 735-2966
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