Form Mo-8453 - Individual Income Tax Declaration For Internet Or Electronic Filing - 2012

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NOT
DO
MAIL
2012
MISSOURI DEPARTMENT OF REVENUE
INDIVIDUAL INCOME TAX DECLARATION
FORM
MO‑8453
TO THE DEPT. OF REVENUE
FOR INTERNET OR ELECTRONIC FILING
POSTMARK DATE
CASH
DCN
DOR USE ONLY
NAME (LAST, FIRST, INITIAL)
SOCIAL SECURITY NO.
_ _ _ ‑ _ _ ‑ _ _ _ _
SPOUSE’S NAME (LAST, FIRST, INITIAL)
SPOUSE’S SOCIAL SECURITY NO.
_ _ _ ‑ _ _ ‑ _ _ _ _
PRESENT ADDRESS (INCLUDE APARTMENT # OR RURAL ROUTE)
TELEPHONE NUMBER
(_ _ _) _ _ _ ‑ _ _ _ _
CITY, TOWN, OR POST OFFICE
STATE
ZIP CODE
__ __ __ __ __
PART 1 — TAX RETURN INFORMATION (WHOLE DOLLARS ONLY)
1. Total federal adjusted gross income (Form MO‑1040, Line 1) ........................................................................................................
1
2. Total Missouri tax (Form MO‑1040, Line 31) ...................................................................................................................................
2
3. Missouri income tax withheld (Form MO‑1040, Line 32)
DOR ONLY
Form W‑2(s) and 1099R(s) must be attached ..........................................................................
3
4. Refund (Form MO‑1040, Line 46) ....................................................................................................................................................
4
5. Amount you owe (Form MO‑1040, Line 49). Please mail amount due with Form MO‑1040V to: Missouri Department of
Revenue, P.O. Box 371, Jefferson City, MO 65105‑0371 or dial (888) 929‑0513 to pay with major credit card. ...........................
5
PART 2 — DECLARATION OF TAXPAYER
Under penalties of perjury, I declare that the information I have provided to my electronic return originator (ERO) or entered via the Internet agree with the amounts shown on the corresponding
lines of my 2012 Missouri Individual Income Tax Return and with Part 1 above. To the best of my knowledge and belief, my return is true, correct, and complete. I consent that my return and
accompanying schedules and statements, if electronically filed, be sent to the Internal Revenue Service (IRS) by my ERO and by the IRS to the Missouri Department of Revenue. I consent
that my return and accompanying schedules and statements, if filed via the Internet, will be retained by me for three years. If I have filed a balance due return, I understand that if the Missouri
Department of Revenue does not receive full and timely payment of my tax liability, I will remain liable for the tax liability and applicable interest and additions to tax. If I have filed a joint Federal
and State tax return and there is an error on my Federal return, I understand my Missouri return may not be forwarded to the Missouri Department of Revenue. If the processing of my return or
refund is delayed, I authorize the Missouri Department of Revenue to disclose to my ERO, practitioner and/or the transmitter the reason(s) for the delay, or when the refund was sent.
I declare, under the penalties of perjury, that I agree to provide the direct deposit information to the Missouri Department of Revenue so my refund check may be deposited into the account
specifically designated. I agree the Missouri Department of Revenue will not be liable for misrouting of direct deposit based upon incorrect account information provided by myself or the ERO.
Check if Direct Deposit
Check if not Direct Deposit
SIGNATURE
DATE(MM/DD/YYYY)
SPOUSE’S SIGNATURE (if filing combined, BOTH must sign)
DATE(MM/DD/YYYY)
_ _ / _ _ / _ _ _ _
_ _ / _ _ / _ _ _ _
PART 3 — DECLARATION OF ELECTRONIC RETURN ORIGINATOR (ERO) AND PAID PREPARER (IF APPLICABLE)
I declare that I have reviewed the above taxpayer’s return and that the entries on Form MO‑8453 are complete and correct to the best of my knowledge. If I am only a collector, I understand
that I am not responsible for reviewing the taxpayer’s return; I declare that Form MO‑8453 accurately reflects the data on the return. I have obtained the taxpayer’s signature on Form MO‑8453
before submitting this return to the Missouri Department of Revenue, have provided the taxpayer with a copy of all forms and information to be filed with the Missouri Department of Revenue
and have followed all other requirements described in the Missouri Handbook for Electronic Filers and any requirements specified by the Missouri Department of Revenue. If I am also the Paid
Preparer, under penalties of perjury, I declare that I have examined the above taxpayer’s return and accompanying schedules and statements, and to the best of my knowledge and belief, they
are true, correct, and complete. This declaration of Paid Preparer is based on all information of which the preparer has any knowledge.
I declare that the direct deposit information transmitted electronically was provided by the taxpayer. I agree I will be liable for reimbursement to the taxpayer or the Missouri Department of
Revenue if the direct deposit is misrouted based on this information and cannot be recovered.
ERO USE ONLY
ERO’S SIGNATURE
DATE
CHECK IF PAID PREPARER
CHECK IF SELF‑EMPLOYED SOCIAL SECURITY NO.
_ _ _ ‑ _ _ ‑ _ _ _ _
_ _ / _ _ / _ _ _ _
FIRM’S NAME (YOURS IF SELF‑EMPLOYED)
TELEPHONE NUMBER
E.I. NO.
(_ _ _) _ _ _ ‑ _ _ _ _
ADDRESS
CITY
STATE
ZIP CODE
__ __ __ __ __
PAID PREPARER USE ONLY
Under penalties of perjury, I declare that I have examined the above taxpayer’s return and accompanying schedules and statements, and to the best of my knowledge and belief, they are true,
correct, and complete. Declaration of preparer is based on all information of which the preparer has any knowledge.
PREPARER’S SIGNATURE
DATE
CHECK IF SELF‑EMPLOYED SOCIAL SECURITY NO.
_ _ _ ‑ _ _ ‑ _ _ _ _
_ _ / _ _ / _ _ _ _
FIRM’S NAME (YOURS IF SELF‑EMPLOYED)
TELEPHONE NUMBER
E.I. NO.
(_ _ _) _ _ _ ‑ _ _ _ _
ADDRESS
CITY
STATE
ZIP CODE
__ __ __ __ __
INSTRUCTIONS FOR PAYMENT ON REVERSE SIDE
CR
P
EI
O
(12‑2012)

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