MISSOURI DEPARTMENT OF REVENUE
P.O. BOX 898
2012
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JEFFERSON CITY, MO 65105‑0898
(573) 751‑2326
TDD 1‑800‑735‑2966
INT-5
FARMER’S COOPERATIVE CREDIT ASSOCIATIONS
INTANGIBLE PROPERTY TAX RETURN
(REV. 09‑2012)
2013 TAXABLE YEAR — BASED ON THE 2012 CALENDAR YEAR INCOME PERIOD
DUE DATE April 15, 2013
NAME
ADDRESS
CITY, STATE, ZIP CODE
FEDERAL EMPLOYER IDENTIFICATION NUMBER
COUNTY NAME
COUNTY CODE
___ ___ ___ ___ ___ ___ ___ ___ ___
PART I
1. Gross income derived from all sources during 2012 ...........................................................................................
1
2. Gross income derived from notes and mortgages ...............................................................................................
2
3. Ratio of Line 2 to Line 1 .......................................................................................................................................
3
%
4. Total of dividends declared and credited (whether paid or not) to share accounts of members in 2012 ............
4
5. Taxable portion of dividends (
% Line 3 multiplied by Line 4) ......................................................
5
6. Amount of tax for 2013 (2% of Line 5) .................................................................................................................
6
6A. Miscellaneous credits (attach schedule) ........................................................................................................
6A
6B. Enterprise Zone Credit...................................................................................................................................
6B
6C. Missouri tax — Line 6 less Lines 6A and 6B .................................................................................................
6C
7. Interest for delinquent payment after April 15, 2013. ...........................................................................................
7
8. Total Amount Due ...............................................................................................................................................
8
PART II — POLITICAL SUBDIVISIONS TAXING THE REPORTING ASSOCIATION
This must be completed — Information is shown on your Real or Personal Property Tax Receipt
SUBDIVISIONS
NAME OR NUMBER
County
City or Town
Road District
School District
Library District
Water District
Sewer District
Fire District
Other Districts
DOR‑INT‑5 (09‑2012)
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