Form 1141 - Application For Financial Institution Tax Credit/refund - 2011

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MISSOURI DEPARTMENT OF REVENUE
FORM
TAXATION DIVISION
P.O. BOX 898, JEFFERSON CITY, MO 65105-0898
1141
(573) 751-2326
TDD 1-800-735-2966
APPLICATION FOR FINANCIAL
(REV. 09-2011)
INSTITUTION TAX CREDIT/REFUND
NAME OF FINANCIAL INSTITUTION
REFUND
CREDIT
MAILING ADDRESS
BANK
CREDIT INSTITUTION
CITY, STATE, ZIP CODE
SAVINGS & LOAN
CREDIT UNION
PLEASE COMPLETE THE FOLLOWING INFORMATION:
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........................................................................
REASON FOR OVERPAYMENT
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I declare this claim and any attached information supporting the claim is true, complete, and correct.
SIGNATURE OF OFFICER
TITLE
DATE
__ __ / __ __ / __ __ __ __

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