Form Int-2 - Bank Franchise Tax Return - 2012 Page 2

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SCHEDULE A — TAXES CLAIMED AS CREDITS
DESCRIPTION (Do not list tangible personal property tax on leased property)
AMOUNT
TOTAL (Enter on Lines 8 and 19B, Page 1)
AUTHORIZATION
I authorize the Director of Revenue or delegate to discuss my return and attachments with the preparer or any member of his/her firm, or if internally prepared, any member
of the internal staff.
YES
NO
SIGNATURE — PLEASE SIGN BELOW
Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and
belief, it is true, correct, and complete. Declaration of preparer (other than taxpayer) is based on all information of which he/she has any knowledge. I declare
under penalties of perjury that I employ no illegal or unauthorized aliens as defined under federal law and that I am not eligible for any tax exemption, credit or
abatement if I employ such aliens. I also declare that I am a business entity, I participate in a federal work authorization program with respect to the employees
working in connection with any contracted services and I do not knowingly employ any person who is an unauthorized alien in connection with any contracted
services.
SIGNATURE OF OFFICER (REQUIRED)
TITLE OF OFFICE
PHONE NUMBER
DATE SIGNED
(__ __ __) __ __ __ ‑ __ __ __ __ __ __ / __ __ /__ __ __ __
PREPARER’S SIGNATURE (INCLUDING INTERNAL PREPARER)
PREPARER’S FEIN, SSN, OR PTIN
PHONE NUMBER
DATE SIGNED
___ ___ ___ ___ ___ ___ ___ ___ ___
(__ __ __) __ __ __ ‑ __ __ __ __
__ __ / __ __ /__ __ __ __
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. MAIL COMPLETED FORM AND ATTACHMENTS TO THE MISSOURI
DEPARTMENT OF REVENUE, P.O. BOX 898, JEFFERSON CITY, MO 65105‑0898.
INT‑2 (12‑2012)

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