Form Rd-104 - Prior Year Business License Adjusted Return
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1PRIOR YEAR BUSINESS LICENSE
RD-104
ADJUSTED RETURN
Phone
(Rev 08/12)
City of Kansas City, Missouri
(816) 513-1135
Revenue Division
Period From:
Period To:
Legal Name
FEIN/SSN:
Mailing Address
Account ID:
DBA Name
Business Address
SIC Code:
For changes to name, address or FEIN/SSN, please contact us at or (816) 513-1135.
To ensure proper crediting, please enclose a separate check for the RD-104.
Missouri Sales Tax No.
GROSS ANNUAL RECEIPTS FOR PRIOR CALENDAR YEAR
ANNUAL FEE DUE
DOLLARS
CENTS
(from table A of instructions)
DOLLARS
CENTS
1. RETAIL/
W HOLESALE/
1a.
1b.
SERVICE:
(from table B of instructions)
2. MANUFACTURER:
2a.
2b.
(from table B of instructions)
3. CONSTRUCTION/
3a.
3b.
REMODELING:
(from appropriate table of instructions form RD-102/104A)
4. MISCELLANEOUS:
4a.
4b.
5. Annual fee (sum of lines 1b, 2b, 3b, and 4b)
5.
6. Credit applied to annual fee due on line 5
6.
Fee paid in prior calendar year____________________________
6a. Annual fee subtotal (line 5 minus line 6) $
7. Penalty: Please see instructions for penalty calculations
7.
Interest: 3% per annum until tax is paid (add Penalty & Interest together)
8. Total amount due (line 6a plus line 7), if negative enter zero
8.
9. If overpaid (line 6 is greater than line 5), am ount of REFUND
9.
requested (if filed timely)
10. If overpaid (line 6 is greater than line 5), am ount of CREDIT
10.
requested (if filed timely)
11. Amount paid
M
M
D
D
Y
Y
/
/
12. Date if closed
Make check payable to: CITY TREASURER. DO NOT SEND CASH Mail to Revenue Division, P.O. Box 803104 Kansas City, MO 64180-3104
Under penalties of perjury, I declare this return to be a true, correct, and complete accounting for the taxable year stated.
I authorize the Comm issioner of Revenue or delegate to discuss m y return and attachments with m y preparer.
Yes
No
Taxpayer Signature
Print Name
Title
Date
Phone
Preparer's Signature (if other than taxpayer) Print Name
Title
Date
Phone
Draft
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