Form 2041 - Use Tax Protest Payment Affidavit
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1
2DOR USE ONLY
MISSOURI DEPARTMENT OF REVENUE
FORM
TAXATION DIVISION
2041
P.O. BOX 3350, JEFFERSON CITY, MO 65105‑3350
(573) 526‑9938
TDD (800) 735‑2966
(REV. 03‑2012)
USE TAX PROTEST PAYMENT AFFIDAVIT
MITS NUMBER
REPORTING PERIOD
___ ___ ___ ___ ___ ___ ___ ___
OWNER’S NAME
BUSINESS NAME
MAILING ADDRESS
PHONE NUMBER
(___ ___ ___) ___ ___ ___ ‑ ___ ___ ___ ___
CITY
STATE
ZIP CODE
___ ___ ___ ___ ___
PPRE
(DO NOT WRITE IN SHADED AREAS)
FPRE
This form is to be used for filing a use tax protest payment in compliance with Section 144.700, RSMo. Return completed form to: Taxation Division, P.O. Box
3350, Jefferson City, MO 65105‑3350.
VENDOR’S USE TAX
TAX TYPE
GROSS RECEIPTS
ADJUSTMENTS
TAXABLE SALES
TAX RATE
AMOUNT OF TAX
STATE USE
3%
BUSINESS LOCATION
CONSERVATION
1/8%
EDUCATION
1%
PARKS/SOIL
1/10%
1.
VENDOR’S TOTALS
ENTER TOTAL AMOUNT OF VENDOR’S USE TAX FROM ALL PAGES
2.
SUBTRACT 2% TIMELY PAYMENT
–
ALLOWANCE (If Applicable)
3.
VENDOR’S USE TAX DUE
=
(Line 1 minus Line 2)
CONSUMER’S USE TAX
TAX TYPE
TAXABLE PURCHASES
TAX RATE
AMOUNT OF TAX
STATE USE
3%
BUSINESS LOCATION
CONSERVATION
1/8%
EDUCATION
1%
PARKS/SOIL
1/10%
CONSUMER’S TOTALS
ENTER TOTAL AMOUNT OF CONSUMER’S USE TAX FROM ALL PAGES
4.
5.
FINAL RETURN: If this is your final return, enter the close date below and check the reason for closing
TOTAL USE TAX DUE:
=
your account. The Use Tax law requires any person selling or discontinuing business to make a final use
(Add Lines 3 and 4)
. . . . . . . . . . . .
6.
tax return within fifteen (15) days of the purchase or closing.
ADD: Interest for late payment
+
(See Instructions) . . . . . . . . . . . . . . .
Date Business Closed:
7.
ADD: Additions to Tax (5% per month
Out of Business
Sold Business
Leased Business
+
late of Line 5, maximum 25%) . . . . . .
8.
REMIT SINGLE CHECK
SIGN AND DATE RETURN: This must be signed and dated by the taxpayer or by the taxpayer’s autho‑
FOR THIS AMOUNT:
=
(Add Lines 5, 6 and 7) . . . . . . . . . . . .
rized agent. Mail to: Missouri Department of Revenue, P.O. Box 3350, Jefferson City, MO 65105‑3350.
If you pay by check, you authorize the Department of Revenue to process the check electronically. Any
check returned unpaid may be presented again electronically.
TAX PERIOD
MONTH
DAY
YEAR
MONTH
DAY
YEAR
I have direct control, supervision or responsibility for filing this return and payment of the tax due. Under the
penalties of perjury, I declare that this is a true, accurate, and complete return. RETURN MUST BE SIGNED
__ __ /__ __ / __ __ __ __
__ __ /__ __ / __ __ __ __
AND DATED.
THRU
SIGNATURE OF TAXPAYER OR AGENT
TITLE
DATE
__ __ / __ __ / __ __ __ __
DOR‑2041 (03‑2012)
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