Form Int-4 - Credit Union Tax Return - 2016 Page 2
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1
2Amount
Description (Do not list real estate taxes or tangible personal property tax on leased property)
Total (Enter on Lines 4 and 17, Page 1)
Total (Enter on Line 10, Page 1)
This section must be completed by credit unions with only one office. If you have more than one office location, you must complete
the Financial Institution Tax Schedule B (Form 2331). Information is available from your real or personal property tax receipt.
Physical Street Address
City, State, and ZIP Code
Subdivisions
Name or Number
County
City
Road District
School District
Library District
Water District
Sewer District
Fire District
Township or Other Tax Districts
I authorize the Director of Revenue or delegate to discuss my return and attachments with the preparer or any
r
r
member of his or her firm, or if internally prepared, any member of the internal staff ..............................................
Yes
No
Under penalties of perjury, I declare that the above information and any attached supplement is true, complete, and correct.
Declaration of preparer (other than taxpayer) is based on all information of which he or she has any knowledge.
Signature of Officer (Required)
Title of Officer
Phone Number
Date (MM/DD/YYYY)
(
)
-
__ __ /__ __ /__ __ __ __
___ ___ ___
___ ___ ___
___ ___ ___ ___
Preparer’s Signature (Including Internal Preparer) Preparer’s FEIN, SSN, or PTIN
Phone Number
Date (MM/DD/YYYY)
(
)
-
__ __ /__ __ /__ __ __ __
___ ___ ___
___ ___ ___
___ ___ ___ ___
Make check or money order payable to “Missouri Department of Revenue”. Mail completed form and attachments to the address below.
If you pay by check, you authorize the Department of Revenue to process the check electronically. Any returned check may be presented
again electronically.
Form INT-4 (Revised 12-2016)
Visit
Mail to:
Taxation Division
Phone: (573) 751-2326
for additional information.
P.O. Box 898
TTY: (800) 735-2966
Jefferson City, MO 65105-0898
Fax: (573) 522-1721
E-mail:
fit@dor.mo.gov
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