Form 4922 - Statutory County Recorder'S Fund
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1DEPARTMENT USE ONLY
FORM
MISSOURI DEPARTMENT OF REVENUE
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4922
TAXATION DIVISION
P.O. BOX 453
(Rev. 09-2010)
JEFFERSON CITY, MO 65105-0453
STATUTORY COUNTY RECORDER’S FUND
(573) 751-5900
COUNTY NAME AND ADDRESS
COLLECTIONS FOR THE MONTH OF:
In the space provided below, enter the number of instruments recorded
TOTAL DUE
CHECK NUMBER
pursuant to sections 1 and 2 of Section 59.330, RSMo.
$
Number of instruments recorded: _______________________________ X 2 =
SIGNATURE OF RECORDER:
DATE:
/
/
__ __
__ __
__ __ __ __
MO 860-2972 (09-2010)
DOR-4922 (09-2010)
DEPARTMENT USE ONLY
FORM
MISSOURI DEPARTMENT OF REVENUE
4922
TAXATION DIVISION
P.O. BOX 453
(Rev. 09-2010)
JEFFERSON CITY, MO 65105-0453
STATUTORY COUNTY RECORDER’S FUND
(573) 751-5900
COUNTY NAME AND ADDRESS
COLLECTIONS FOR THE MONTH OF:
In the space provided below, enter the number of instruments recorded
TOTAL DUE
CHECK NUMBER
pursuant to sections 1 and 2 of Section 59.330, RSMo.
$
Number of instruments recorded: _______________________________ X 2 =
SIGNATURE OF RECORDER:
DATE:
/
/
__ __
__ __
__ __ __ __
MO 860-2972 (09-2010)
DOR-4922 (09-2010)
DEPARTMENT USE ONLY
FORM
MISSOURI DEPARTMENT OF REVENUE
4922
TAXATION DIVISION
P.O. BOX 453
(Rev. 09-2010)
JEFFERSON CITY, MO 65105-0453
STATUTORY COUNTY RECORDER’S FUND
(573) 751-5900
COUNTY NAME AND ADDRESS
COLLECTIONS FOR THE MONTH OF:
In the space provided below, enter the number of instruments recorded
TOTAL DUE
CHECK NUMBER
pursuant to sections 1 and 2 of Section 59.330, RSMo.
$
Number of instruments recorded: _______________________________ X 2 =
SIGNATURE OF RECORDER:
DATE:
/
/
__ __
__ __
__ __ __ __
MO 860-2972 (09-2010)
DOR-4922 (09-2010)
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