Form 1315a - Monthly Statement Of Collections Page 2

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STATEMENT

MISSOURI DEPARTMENT OF REVENUE

MONTHLY STATEMENT OF TOWNSHIP COLLECTIONS

OF COLLECTIONS

GROSS COLLECTIONS MUST BE REPORTED IN ALL CASES

MADE BY

, Clerk of the County Commission within and for the County of

hereby certify to the Director of Revenue, that from the monthly statements filed in my office, and sworn to by the several Township Collectors of said County, it appears that they

COLLECTOR OF

have collected for State purposes during the month of

, 20

, the following amounts, viz:

COLLECTOR

TOWNSHIP

TAX

INTEREST

TOTAL

COUNTY

DURING THE MONTH OF

, 20