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MISSOURI DEPARTMENT OF REVENUE

INDIVIDUAL INCOME TAX PAYMENT VOUCHER INSTRUCTIONS

What Is Form MO-1040V and Why Should I Use It?

How Do I Make My Payment?

Form MO-1040V, Individual Income Tax Payment Voucher, is the voucher

• Make your check or money order payable to the “Missouri Department

you send with your payment when you do not make the payment with your

of Reve n ue.” Do not send cash (U.S. funds only). Do not postdate your

income tax return. It is similar to vouchers returned with loan, utility, and

check; it will be cashed upon receipt. The Department of Revenue may

credit card payments. Form MO-1040V ensures that your payment will be

collect checks returned for insufficient or uncollected funds electronically.

processed more efficiently and accurately. Form MO-1040V allows you

• Write your name, address, SSN, daytime telephone number, and

to file your completed income tax return and send your payment at a later

“2012 MO Income Tax” on your check or money order.

date. Your income tax return and payment are due no later than April

• Detach the payment voucher at the perforation, and mail with your

15, 2013.

payment.

When Should I Use Form MO-1040V?

• Please mail your Form MO-1040V and payment to:

If you have an amount due on an electronically filed return, or do not

Missouri Department of Revenue

submit payment in full when you file your income tax return, send Form

P.O. Box 371

MO-1040V with your payment.

Jefferson City, MO 65105-0371

How Do I Fill In the Payment Voucher?

Please print as shown below in black or dark blue ink. Do not use

Complete the name(s) and address block. Use the label from the front

red ink or pencil.

cover of your book if the address information on the label is correct.

1 2 3 4

A B C D

Line 1 — Enter your social security number (SSN) on Line 1. If you are

filing a combined return, enter on Line 1 the first SSN as shown on your

return.

Federal Privacy Notice

Line 2 — Enter the first four letters of your last name on Line 2.

The Federal Privacy Act requires the Missouri Department of Revenue (Department) to inform

See examples.

}

taxpayers of the Department’s legal authority for requesting identifying information, including

NAME

ENTER

social security numbers, and to explain why the information is needed and how the informa-

tion will be used.

John Brown

BROW

Chapter 143 of the Missouri Revised Statutes authorizes the Department to request informa-

Juan De Jesus

DEJE

tion necessary to carry out the tax laws of the state of Missouri. Federal law 42 U.S.C. Section

Please use capital

Joan A. Lee

LEE

405 (c)(2)(C) authorizes the states to require taxpayers to provide social security numbers.

letters as shown.

Jean McCarthy

MCCA

The Department uses your social security number to identify you and process your tax returns

and other documents, to determine and collect the correct amount of tax, to ensure you are

John O’Neill

ONEI

complying with the tax laws, and to exchange tax information with the Internal Revenue

Pedro Torres-Lopez

TORR

Service, other states, and the Multistate Tax Commission (Chapters 32 and 143, RSMo). In

addition, statutorily provided non-tax uses are: (1) to provide information to the Department

Line 3 — If you are filing a combined return, enter on Line 3 your spouse’s

of Higher Education with respect to applicants for financial assistance under Chapter 173,

SSN.

RSMo and (2) to offset refunds against amounts due to a state agency by a person or entity

(Chapter 143, RSMo). Information furnished to other agencies or persons shall be used solely

Line 4 — Enter the first four letters of your spouse’s last name on Line 4.

for the purpose of administering tax laws or the specific laws administered by the person

See examples for Line 2, above.

having the statutory right to obtain it [as indicated above]. In addition, information may be

disclosed to the public regarding the name of a tax credit recipient and the amount issued to

Line 5 — Enter the amount of your payment in whole dollars on Line 5.

such recipient (Chapter 135, RSMo). (For the Department’s authority to prescribe forms and

to require furnishing of social security numbers, see Chapters 135, 143, and 144, RSMo.)

You are required to provide your social security number on your tax return. Failure to pro-

vide your social security number or providing a false social security number may result in

criminal action against you.

(12-2012)

2012

1. Social

security number .............

FORM

INDIVIDUAL INCOME TAX

2. Name

MO-1040V

PAYMENT VOUCHER

control . ...........................

PLEASE PRINT. MAKE CHECK PAYABLE TO MISSOURI DEPARTMENT OF REVENUE.

3. Spouse’s social

MAIL FORM MO-1040V AND PAYMENT TO THE MISSOURI DEPARTMENT OF

security number .............

REVENUE, P.O. BOX 371, JEFFERSON CITY, MO 65105-0371.

4. Spouse’s name

NAME

control . ..........................

5. Amount of payment

0 0

SPOUSE’S NAME

•

(U.S. funds only) ............

STREET ADDRESS

CITY

STATE ZIP CODE

FULL PAYMENT OF TAXES MUST BE SUBMITTED BY APRIL 15, 2013 TO AVOID

•

INTEREST AND ADDITION TO TAX FOR FAILURE TO PAY. If you pay by check, you

DOR USE ONLY

authorize the Department of Revenue to process the check electronically. Any returned

check may be presented again electronically.

• PLEASE SEND CHECK OR MONEY ORDER (U.S. FUNDS ONLY)

MO-1040V (12-2012)

Instructions For Form Mo-1040a - Single/married (Income From One Spouse) Short Form - 2012 Page 10

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