Form S - Surplus Lines Tax Remittance - Missouri Department Of Revenue
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1MISSOURI DEPARTMENT OF REVENUE
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POST OFFICE BOX 898
JEFFERSON CITY MO, 651050898
SURPLUS LINES TAX REMITTANCE
FORM S
SEND THIS FORM AND CHECK TO Missouri Department of Revenue at the above address. Payment must be postmarked by April 15th.
Note: When the due date falls on a Saturday, Sunday, or legal holiday, the payment will be considered timely if made on the next business day.
SL NUMBER
M
M
D
D
Y
Y
Y
Y
DEPARTMENT OF
SL
REVENUE USE ONLY
SURPLUS
LICENSEE
NAME
AGENCY NAME
ADDRESS
CITY
STATE
ZIP CODE
TAX YEAR
REMITTANCE AMOUNT
Make check or money order payable to “Missouri Department of Revenue”. If you pay by check, you authorize the Department of
Revenue to process the check electronically. Any returned check may be presented again electronically.
Send this original with your remittance. Make a copy of this notice for your records.
All claims for refunds must be filed in accordance with Section 136.035, RSMo.
Delinquent tax, penalty, interest.
384.054. Any tax imposed by sections 384.011 to 384.071 which is delinquent in payment shall be subject to a penalty of one percent of
the tax per diem up to ten percent of the tax. Any delinquent tax shall bear interest at the rate determined under section 32.065, RSMo, from
the time such tax is due.
If you have any questions, please contact the Missouri Department of Insurance, Financial Institutions and Professional Registration at (573)
7510669 or (573) 5261589.
SURPLUS LINES LICENSEE SIGNATURE
DATE
MO 3750702 (909)
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