Form 53-V - Vendor'S Use Tax Return - 2017 Page 2

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Missouri Tax Identification Number
Reporting Period
Page
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Owner Name
Business Name
Taxable
Adjustments
Business Location
Code
Gross Receipts
Rate (%)
Amount of Tax
Sales
(Indicate + or -)
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Page _______ Totals . . . . . . . . . . . . . . . . . . . .
Form 53-V (Revised 01-2017)

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