Form 1141 - Application For Financial Institution Tax Credit Or Refund - 2013
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Missouri Department of Revenue
Form
Application for Financial Institution Tax
1141
Credit or Refund
Financial Institution Type:
r
r
r
r
r
r
Refund
Credit
Bank
Credit Institution
Credit Union
Savings and Loan
Name of Financial Institution
Mailing Address
City
State
Zip Code
1. For taxable year__________ based on the calendar year income period ___________.
2
2. Amount of tax paid...........................................................................................................
Dates of payments: ________________________________________________
3
3. Amount to be credited or refunded ..................................................................................
Under penalties of perjury, I declare the information I have provided and any attached supplement is true, complete, and correct.
Signature of Officer
Title
Date (MM/DD/YYYY)
__ __ / __ __ / __ __ __ __
Printed Name of Officer
E-mail Address of Officer
Form 1141 (Revised 07-2013)
Mail to:
Taxation Division
Phone: (573) 751-2326
Visit
P.O. Box 898
Fax: (573) 522-1721
for additional information.
Jefferson City, MO 65105-0898
E-mail:
fit@dor.mo.gov
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Parent category: Financial