Form Mo-1040v - Individual Income Tax Payment Voucher - 2012

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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
• Make your check or money order payable to the “Missouri Department
voucher you send with your payment when you do not make the
of Reve nue.” Do not send cash (U.S. funds only). Do not postdate
payment with your income tax return. It is similar to vouchers returned
your check; it will be cashed upon receipt. The Department of Revenue
with loan, utility, and credit card payments. Form MO‑1040V ensures
may collect checks returned for insufficient or uncollected funds
that your payment will be processed more efficiently and accurately.
electronically.
Form MO‑1040V allows you to file your completed income tax return and
• Write your name, address, SSN, daytime telephone number, and
send your payment at a later date. Your income tax return and payment
“2012 MO Income Tax” on your check or money order.
are due no later than April 15, 2013.
• Detach the payment voucher at the perforation, and mail with your
payment.
When Should I Use Form MO-1040V?
If you have an amount due on an electronically filed return, or do not
• Please mail your Form MO-1040V and payment to:
submit payment in full when you file your income tax return, send Form
Missouri Department of Revenue
MO‑1040V with your payment.
P.O. Box 371
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
Complete the name(s) and address block. Use the label from the front
use red ink or pencil.
cover of your book if the address information on the label is correct.
Line 1 — Enter your social security number (SSN) on Line 1. If you are
1 2 3 4
A B C D
filing a combined return, enter on Line 1 the first SSN as shown on your
return.
Federal Privacy Notice
The Federal Privacy Act requires the Missouri Department of Revenue (Department) to
Line 2 — Enter the first four letters of your last name on Line 2. See
inform taxpayers of the Department’s legal authority for requesting identifying information,
examples.
including social security numbers, and to explain why the information is needed and how
}
NAME
ENTER
the information will be used.
John Brown
BROW
Chapter 143 of the Missouri Revised Statutes authorizes the Department to request infor-
mation necessary to carry out the tax laws of the state of Missouri. Federal law 42 U.S.C.
Juan De Jesus
DEJE
Section 405 (c)(2)(C) authorizes the states to require taxpayers to provide social security
Please use capital
Joan A. Lee
LEE
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
John O’Neill
ONEI
ensure you are complying with the tax laws, and to exchange tax information with the
Pedro Torres‑Lopez
TORR
Internal Revenue Service, other states, and the Multistate Tax Commission (Chapters 32
and 143, RSMo). In addition, statutorily provided non-tax uses are: (1) to provide infor-
Line 3 — If you are filing a combined return, enter on Line 3 your
mation to the Department of Higher Education with respect to applicants for financial
spouse’s SSN.
assistance under Chapter 173, 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
Line 4 — Enter the first four letters of your spouse’s last name on Line 4.
agencies or persons shall be used solely for the purpose of administering tax laws or
See examples for Line 2, above.
the specific laws administered by the person having the statutory right to obtain it [as
indicated above]. In addition, information may be disclosed to the public regarding the
Line 5 — Enter the amount of your payment in whole dollars on Line 5.
name of a tax credit recipient and the amount issued to 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
provide your social security number or providing a false social security number may result
in criminal action against you.
(12-2012)
Reset Form
Print Form
2012
1. Social
*
MISSOURI DEPARTMENT OF REVENUE
security number .............
FORM
INDIVIDUAL INCOME TAX
MO-1040V
2. Name
*
PAYMENT VOUCHER
control ............................
REV. (12-2012)
PLEASE PRINT. MAKE CHECK PAYABLE TO MISSOURI DEPARTMENT OF
3. Spouse’s social
*
REVENUE.
MAIL FORM MO-1040V AND PAYMENT TO THE MISSOURI
security number .............
DEPARTMENT OF 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)

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