Form MO-1040_Fillable_Calculating Individual Income Tax Return - Fillable and Calculating Form (NOTE: For proper form functionality, utilize Internet Explorer browser and Adobe Reader for PDF viewer.)

$ $ $ 00 00 00 00 0 00 10 00 11 00 12 00 13 00 14 00 15 00 16 0 00 17 00 18 0 Carry amounts to MO 1040 Line 1Y and 1S CHECK to fill Line 27S CHECK to fill Line 27Y If you are filing an individual income tax return and you have only one Benefit Number: Include a copy of your certificate/form from the issuing agency Use worksheet values in NRI Part C Line 1 Yourself or One Income Filer Spouse (on a Combined Return) (Missouri source from Form MO 1040 Line 2) (See Instr ) * Must be approved by the issuing agency 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 1 2 Enter the amount of income from Form MO 1040 Line 6 or Form MO 1040P Line 4 Enter the amount of nontaxable social security benefits received by you and your minor children 1 0 1 Missouri income Enter wages salaries etc from Missouri (You must file a 1 NONRESIDENT OF MISSOURI What was your state of residence during 2011? 1 Wages salaries tips etc 2 Taxable interest income 3 Dividend income 4 State and local income tax refunds 5 Alimony received 6 Business income or (loss) 7 Capital gain or (loss) 8 Other gains or (losses) 9 Taxable IRA distributions 10 Taxable pensions and annuities 11 Rents royalties partnerships S corporations trusts etc 12 Farm income or (loss) 13 Unemployment compensation 14 Taxable social security benefits 15 Other income 16 Total (add Lines 1 through 15) 17 Less: federal adjustments to income 18 Federal adjusted gross income (Line 16 less Line 17) Enter amounts here and on Lines 1Y and 1S Form MO 1040 1 7 7 10 If married and filing combined; b Enter $2 000 if you rented or did not own your home for the entire year; c Enter $4 000 if you owned and occupied your home for the entire year; Net household income Subtract Line 9 from Line 8 and enter the amount; mark the box that applies a If you rented or did not own and occupy your home for the entire year Line 10 cannot exceed $27 500 OffOffOff 100% (Round to a whole percent such as 91% instead of 90 5% and 90% instead of 90 4% Off 11 If the total is greater than $27 500 STOP no credit is allowed Do not file this claim b If you owned and occupied your home for the entire year Line 10 cannot exceed $30 000 If the total is greater than $30 000 STOP no credit is allowed Do not file this claim Off 12 If you rented enter amount from Form MO CRP Line 9 Attach rent receipts or a statement from your landlord NOTE: If you rent from a facility that does not pay property tax you are not eligible for a Property Tax Credit 12 13 14 Add Lines 11 and 12 If you rented your home enter the total or $750 whichever is less If you owned your home enter the total or $1 100 whichever is less Apply Lines 10 and 13 to the chart in the instructions for MO 1040 pages 41 43 or MO 1040P pages 29 31 to figure your Property Tax Credit You must use the chart to see how much credit you are allowed Note: Renters maximum allowed is $750 Owners maximum allowed is $1 100 Enter this amount on Form MO 1040 Line 38 or Form MO 1040P Line 20 13 14 15 Multiply Line 14 by the percentages found on Lines 9Y and 9S Enter the amounts on Line 15Y and 15S of this worksheet on Line 11 of Form MO A 15Y 15S 2 8a 8a 2 PART YEAR MISSOURI RESIDENT 2 Taxpayer s total adjusted gross income (from Form MO 1040 Lines 5Y and 5S 2011 FORM MO NRI PAGE 2 3 13 19 3 before any deductions and the amount of social security equivalent railroad retirement benefits Attach a copy of Form SSA 1099 and RRB 1099 Enter the total amount of pensions annuities dividends rental income or interest income not included in Line 1 2 3 MISSOURI INCOME PERCENTAGE (divide Line 1 by Line 2) If greater than 100% enter Check boxes to carry amount to MO 1040 with values below 4 15 22 0 4 21 37 0 4 Enter the amount of railroad retirement benefits (not included in Line 2) before any deductions Attach Form RRB 1099 R (Tier II) If filing Form MO 1040 refer to Form MO A Part 1 Line 9 4 40 41 43 44 46 Overpayment to be refunded to you Subtract Lines 44 and 45 from Line 43 and enter here Sign below and mail return to: Department of Revenue PO BOX 3222 JEFFERSON CITY MO 65105 3222 REFUND 5 6 Enter the amount of veterans payments or benefits before any deductions Attach letter from Veterans Affairs Enter the total amount received by you and your minor children from: public assistance SSI child support or 5 7 8 9 Enter the amount of nonbusiness loss(es) You must include nonbusiness losses in your household income (as a positive amount) here (Include capital loss from Federal Form 1040 Line 13 ) TOTAL household income Add Lines 1 through 7 Enter total here Mark the box that applies and enter the appropriate amount a Enter $0 if filing status is Single or Married Living Separate; Off 7 8a 9a none none none 10 none 11b 12b none none 13 14b none 15 20 8609 (first year) HCC Health Care Access Certificate * SCT Shared Care Must Register Each A 65 years of age or older (Attach a copy of Form A Amount paid for audit B Amount paid to implement recommendations C Total Paid Add Lines A and B and enter here Enter Line C or $1 000 whichever is less on Line 13 of Form MO A If you are filing a combined return you may split the amount reported on Line 13 between both taxpayers A A Enter the amount paid for qualified long term care insurance A Federal audit Enter date of IRS report a Indicate the date you were a Missouri resident in 2011 a Routing Number A Wages salaries tips etc a) Did not have any Missouri income other than military income were not in Missouri for more than 30 days did not maintain a home in Missouri during the year but did maintain living quarters elsewhere you qualify as a nonresident for tax purposes Complete Part A Line 3 and enter 0 on Part C Line 1 Add the amounts from 7Y and 7S 8 Add the amounts from Lines 5 and 6 If you itemized on your federal return and your federal itemized deductions included health insurance premiums as medical expenses go on to Line 8 If not enter amounts from 7Y and 7S on Line 11 of Form MO A 7Y 7S Additioinal Additional ADDRESS Adjusted Gross Income Worksheet for Combined Return Federal Form 1040EZ Line No Federal Form 1040A Line No Federal Form 1040 Line No Y Yourself S Spouse AFI Alternative Fuel Infrastructure (573) 751 2254 Certificate* CPC Charcoal Producers (573) 751 4817 Certificate* WEC Processed Wood Energy (573) 526 1723 Certificate*P O BOX 567 JEFFERSON CITY MO 65102 0567 After School the right See AHC Affordable Housing Assistance (816) 759 6662 Certificate* Alpha Attach to Alpha Attach to Alpha Attach to Code Name of Credit and Phone Number Form MO TC Code Name of Credit Form MO TC AMENDED RETURN Amended Return total payments and credits Add Line 40 to Line 39 or subtract Line 41 from Line 39 Amount of Line 43 to be applied to your 2012 estimated tax Amount paid on original return and on Form MO 1040 Lines 27Y and 27S 3 % 3 % 00 and you are not required to file a Missouri return) 2 00 2 00 00 Any taxpayer who paid an individual certified by the Department of Natural Resources to complete a home energy audit may deduct 100% of the costs incurred for the audit and the implementation of any energy efficiency recommendations made by the auditor The maximum yearly subtraction may not exceed $1 000 for a single taxpayer or a married couple filing a combined return The maximum total lifetime subtraction you may claim is $2 000 To qualify for the deduction you must have incurred expenses in the taxable year for which you are filing a claim and the expenses incurred must not have been excluded from your federal adjusted gross income or reimbursed through any other state or federal program QUALIFICATIONS INSTRUCTIONS IN THE SPACES PROVIDED BELOW: Report the name of the auditor who conducted the audit Report the auditor s certification number Summarize each of the auditor s recommendations Enter the amount paid for the audit on Line A ADDRESS CITY STATE ZIP Enter the total amount paid to implement the energy efficiency recommendations on Line B Enter the total amount paid for the audit and any implemented recommendations on Line C Attach applicable receipts Attach completed MO HEA and receipts to Form MO 1040 APU Agricultural Product Utilization Contributor Certificate* Preservation Act (573) 522 8004 Certificate* FFC Family Farms Act Certificate* REC Qualified Research Expense (573) 526 0124 Certificate* NGC New Generation Cooperative Incentive Certificate* RTC Remediation (573) 522 8004 Certificate* ATC Special Needs Adoption Form ATC Attach a copy of PAID real estate tax receipt(s) If your home is on more than five acres or you own a mobile home attach Form 948 Assessor s Certification 11 Attach a copy of your Federal Form 1040 (pages 1 and 2) and Federal Schedule A (if you itemized your deductions) ATTACH TO FORM MO 1040 ATTACH A COPY OF YOUR FEDERAL RETURN See information beginning on page 11 to assist you Attachment Sequence No 1040 01 Attachment Sequence No 1040 07 and 1040P 01 B 100% Disabled Veteran as a result of military service b Account Number B Enter the amount from Federal Schedule A Line 4 B) $ b Indicate other state of residence and date you resided there B Net operating loss carryback Enter year of loss B Taxable interest income b) Did have Missouri income other than military income were in Missouri for more than 30 days or maintained a home in Missouri during the year you cannot use this form You must file Form MO 1040 because 100 percent of your income is taxable including your military income Do not complete this form c) Did not have Missouri income other than military income but spent more than 30 days in Missouri or maintained a home in Missouri during the year you must b) Only had military income while in Missouri you may complete a No Return Required Military Online Form at the following address: http://dor mo gov/personal/individual/ BEC Bond Enhancement (573) 522 9062 Certificate* BFC New or Expanded Business Facility (573) 522 2790 Schedule 150 Fed K 1 BFT Bank Franchise Tax Form INT 2 INT 2 1 Form 4354 BIRTHDATE BTC Bank Tax Credit for S Corporation Form BTC and Form BJI Brownfield Jobs and Investment (573) 522 8004 Certificate* Shareholders INT 3 2823 INT 2 CBC Community Bank Investment (573) 522 8004 Certificate*Fed K 1 DAL Distressed Area Land Assemblage (573) 522 8004 Certificate* CIC Children In Crisis Contribution Verification DFH Dry Fire Hydrant (573) 751 4539 Certificate* from IssuingAgency DPC Development Tax Credit (573) 526 3285 Certificate* DAC Disabled Access Federal Form 8826 andDTC Demolition (573) 522 8004 Certificate* Form MO 8826EZC Enterprise Zone (573) 751 4539 Schedule 250 Fed K 1 DAT Residential Dwelling Accessibility Form MO DAT Form 4354 FPT Food Pantry Tax Form MO FPT FDA Family Development Account (573) 526 5417 Certificate* SHC Self Employed Health Insurance Form MO SHCFPC Film Production (573) 751 9048 Certificate* SSC Public Safety Officer Surviving Spouse Form MO SSC HPC Historic Preservation (573) 522 8004 Certificate* ISB Small Business Investment (Capital) (573) 522 2790 Certificate* MQJ Missouri Quality Jobs (573) 751 4539 Certificate* NAC Neighborhood Assistance (573) 751 4539 Certificate* NEC New Enterprise Creation (573) 522 2790 Certificate* BUC Missouri Business Use Incentives for Large Certificate* http://www dss mo gov/dfas/taxcredit/index htm (573) 751 7533 C 100% Disabled (Attach a copy of the letter from Social SSA 1099 ) C Dividend income C Enter the amount from Federal Schedule A Line 1 C) $ C Investment tax credit carryback Enter year of credit Checking CITY STATE ZIP CODE Code Name of Credit and Phone Number Form MO TC Code Name of Credit Form MO TC Code Name of Credit Form MO TC JEFFERSON CITY MO 65109 COMBINED RETURN) Complete this worksheet if you included health insurance premiums paid as an itemized deduction or had health insurance premiums withheld from your social security benefits D 60 years of age or older and received surviving (Attach a copy of the letter from Department of spouse benefits (Attach a copy of Form SSA 1099 ) Off D Correction other than A B or C Enter date of federal amended return if filed D Enter the amount of qualified long term care included on Line C D) $ 0 D State and local income tax refunds Date From: Date From: Date To: Date To: DAYTIME TELEPHONE deductions included medical expenses go to Line B If not skip to H Divide Line 11 by Line 10 (round to full percent) 12 Divide Line 2 by Line 1 3 % Yourself Spouse Divide Line 7Y and 7S by the total found on Line 8 9Y 9S Don't do any calculations Do automatic calculations DRC Development Reserve Certificate* Code Name of Credit Form MO TC DVC Shelter for Victims of Domestic Violence Certificate* E Alimony received E MAIL ADDRESS E SubtractLineDfromLineC E)$ EFC Export Finance Certificate* EMPLOYEE FIRST MIDDLE IN NAME ITIAL LAST EMPLOYEE SOCIAL SECURITY NUMBER EMPLOYEE TITLE/ POSITION CODE COUNTY WHERE EMPLOYEE WORKED ANNUAL COUNTY AVERAGE WAGE TOTAL WAGES PAID FOR 52 CONSECUTIVE WEEKS TOTAL DEDUCTION Enter amount from Line 14a (federal Form 1040A) or 20a (federal Form 1040) If $0 skip to Line 6 and enter your total health insurance premiums paid 1 Enter amount from Line 14b (federal Form 1040A) or 20b (federal Form 1040) 2 Enter the amount from Federal Schedule A Line 1 10 Enter the amount from Schedule A Line 4 11 Enter the amount of your donation in the Enter the health insurance premiums withheld from your social security income 4Y 4S Enter the total of all other health insurance premiums paid which were not included in 4Y or 4S 6Y 6S F Business income or (loss) F Subtract Line E from Line B If amount is less than zero enter 0 F) $ 0 Fed K 1 8609A FEDERAL FEIN SSN OR PTIN file Form MO 1040 because 100 percent of your income is taxable including your military income Do not complete this form d) Are married to a Missouri resident who is not in the military but lives with you outside of Missouri on military orders you may use Form MO NRI to calculate your Missouri income percentage However any income earned by your spouse is taxable to Missouri Your spouse is not eligible to complete Form MO NRI filing a corporation franchise tax return use Column 2 For Privacy Notice see instructions For Privacy Notice see instructions For Privacy Notice see instructions MO 860 1089 (12 2011) For Privacy Notice see instructions MO 860 1095 (12 2011) For Privacy Notice see the instructions MO TC (12 2011) FORM 1040A LINE NO Fund Code fund codes 45 Fund FundFund FundFund G Capital gain or (loss) G SubtractLineFfromLineA G)$ General H Enter Line G (or Line A if you did not have to complete Lines B through G) on Form MO 1040 Line 17 H Other gains or (losses) However if percentage is less than 0 5% use the exact percentage ) Enter percentage here http://www ded mo gov http://dor mo gov/ (573) 526 8733 or (573) 751 4541 http://www dhss mo gov (800) 235 5503 http://www dnr mo gov http://www mdfb org (573) 751 8479 http://www mhdc com I authorize the Director of Revenue or delegate to discuss my return and attachments I declare under penalties of perjury that I employ no illegal or unauthorized aliens as defined under federal law and that I am not eligible for any tax exemption credit or abatement if I employ such aliens I also declare that if I am a business entity I participate in a federal work authorization program with respect to the employees working in connection with any contracted services and I do not knowingly employ any person who is an unauthorized alien in connection with any contracted services I Taxable IRA distributions IDC Infrastructure Development Certificate* If Line 31 is larger than Line 39 or Line 42 enter the difference (amount of UNDERPAYMENT) here If Line 39 or if amended return Line 42 is larger than Line 31 enter difference (amount of OVERPAYMENT) here If married filing combined If you are filing a combined return and both you and your spouse have Alpha Code: income use Column 1 for yourself and Column 2 for your spouse This is the three character code located on the back of the form Each credit If you are filing a corporation income tax return use Column 1 If you are If you are filing a fiduciary return use Column 1 is assigned an alpha code to ensure proper processing of the credit claimed If you had premiums withheld from your social security benefits complete Lines 1 through 4 to determine your taxable percentage of social security income and the corresponding taxable portion of your health insurance premiums included in your taxable income If you itemized on your federal return and your federal itemized If you owned your home enter the total amount of property tax paid for your home less special assessments 10 0 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 If you would like your refund deposited directly to your checking or savings account complete boxes a b and c below in completing this form Include tax exempt interest from Form MO A Part 1 Line 7 (if filing Form MO 1040) Attach Forms W 2 1099 1099 R 1099 DIV 1099 INT 1099 MISC etc 3 income use Column 1 The number is located on your Certificate of Eligibility Schedule (Certificate) Indicate other state of residence and date you resided there Indicate the date you were a Missouri resident in 2011 INDIVIDUAL INCOME TAX RETURN LONG FORM Individuals with speech/hearing impairments may call TDD (800) 735 2966 or fax (573) 526 1881 MO TC (12 2011) INITIAL Instructions instructions for trust J Taxable pensions and annuities JEFFERSON CITY MO 65105 K Rents royalties partnerships S corporations trusts etc L Farm income or (loss) LAST NAME FIRST NAME INITIAL LHC Missouri Low Income Housing (816) 759 6668 Eligibility Statement M Unemployment compensation Married Filing Combined Married Living Separate for Entire Year Memorial MHC Maternity Home Certificate* PRC Pregnancy Resource Certificate* RTA Residential Treatment Agency Certificate* 3435 BROADWAY KANSAS CITY MO 64111 MILITARY NONRESIDENT STATIONED IN MISSOURI If you are a military nonresident stationed in Missouri and you: a) Earned non military income while in Missouri you must file Form MO 1040 Complete Part A Line 3 Part B and Part C The nonresident military pay should be subtracted from your federal adjusted gross income using Form MO A Part 1 Line 9 as a Military (nonresident) Subtraction MilitaryChildhoodChildren s Veterans Elderly Home Miscellaneous tax credits are administered by various agencies For more information forms and approval to claim these credits contact the following Departments Visit http://dor mo gov/taxcredit/ for a description of each credit and more contact information for agencies administering each credit Missouri MISSOURI DEPARTMENT OF REVENUE MISSOURI DEPARTMENT OF REVENUE 2011 FORM MO 1040 MISSOURI DEPARTMENT OF REVENUE HOME ENERGY AUDIT EXPENSE 2011 FORM MO HEA Missouri law requires a combined return for spouses filing together A combined return means taxpayers are required to split their total federal adjusted gross income (including other state income) between spouses when beginning the Missouri return Splitting the income can be as easy as adding up your separate Forms W 2 and 1099 Or it may require allocating to each spouse the percentage of ownership in jointly held property such as businesses farm operations dividends interest rent and capital gains or losses State refunds should be split based on each spouse s 2010 Missouri tax withheld less each spouse s 2010 tax liability The result should be each spouse s portion of the 2010 refund Taxable social security benefits must be allocated by each spouse s share of the benefits received for the year The worksheet below lists income that is included on your federal return along with federal line references Find the lines that apply to your federal return split the income between you and your spouse and enter the amounts on the worksheet When you have completed the worksheet transfer the amounts from Line 18 to Form MO 1040 Lines 1Y and 1S Note: Remember the incomes listed separately on Line 18 of this worksheet must equal your total federal adjusted gross income when added together WORKSHEET FOR LINE 1 Instructions for Completing the Adjusted Gross Income Worksheet Missouri return if the amount on this line is more than $600 ) 1 00 1 00 MISSOURI SOURCES MO 860 1094 (12 2011) MO 860 1096 (12 2011) MO 860 1881 (12 2011) MO 860 1881 (12 2011)Carry amount to 1040 Line 14 MO 860 2993 (12 2011) MO HEA (10 2011) MO NJD (11 2011) MO PTS Multiply Line 8 by percent on Line 12 13 Multiply the amounts on Line 4Y and 4S by the percentage on Line 3 5Y 5S N Taxable social security benefits NAME OF AUDITOR AUDITOR CERTIFICATION NUMBER 1 SUMMARY OF RECOMMENDATIONS NAME OF TAXPAYER National Guard NEZ New Enhanced Enterprise Zone (573) 751 4539 Certificate* http://www mda mo gov (573) 751 2129 NMC New Market Tax Credit (573) 522 8004 Certificate* Alpha Attach to none 10 13 none 11b 15b none 12b 16b none 14b 20b none 20 36 none 9a 9a none none 10 none none 11 none none 12 none none 14 none none 17 none none 18 none none 21 NOTE: IF YOU FILE A JOINT FEDERAL RETURN YOU MUST FILE A COMBINED MISSOURI RETURN (REGARDLESS OF WHOM EARNED THE INCOME) COMPLETE EACH COLUMN OF PART B AND PART C OF THIS FORM DO NOT COMBINE INCOMES FOR YOU AND YOUR SPOUSE NOYES O Other income OffOffOff ONE INCOME FILER or from your federal form if you are a military nonresident Organ Donor Overpayment as shown (or adjusted) on original return INDICATE REASON FOR AMENDING P O BOX 118 JEFFERSON CITY MO 65102 0118 P O BOX 2200 JEFFERSON CITY MO 65105 2200 P O BOX 570 JEFFERSON CITY MO 65102 0570 P O BOX 630 JEFFERSON CITY MO 65102 0630 P Total Add Lines A through O PAGE 2 PART 3 PENSION AND SOCIAL SECURITY/SOCIAL SECURITY DISABILITY/MILITARY EXEMPTION PART A LINE 1: NONRESIDENTS OF MISSOURI If you are a Missouri nonresident and had Missouri source income complete Part A Line 1 Part B and Part C Attach a copy of your federal return and this form to your Missouri return PART A LINE 2: PART YEAR RESIDENT If you were a Missouri part year resident with Missouri source income and income from another state; you may use Form MO NRI or Form MO CR whichever is to your benefit When using Form MO NRI complete Part A Line 2 Part B and Part C Missouri source income includes any income (pensions annuities etc ) that you received while living in Missouri Attach a copy of your federal return and this form to your Missouri return PART A LINE 3: MILITARY NONRESIDENT TAX STATUS MISSOURI HOME OF RECORD If you have a Missouri home of record and you: PART C MISSOURI INCOME PERCENTAGE PAYMENTS / CREDITS policy A)$ PREPARER S ADDRESS AND ZIP CODE PREPARER S SIGNATURE PREPARER S TELEPHONE Program Fund PROPERTY TAX CREDIT Q Less: federal adjustments to income QBC Qualified Beef Certificate* R SUBTOTAL (Line P Line Q) If no modifications to income STOP and ENTER this amount on reverse side Part C Line 1 RCC Rebuilding Communities (573) 526 3285 Certificate* Code Name of Credit Form MO TC RCN Rebuilding Communities and Neighborhood REFUND Resident Retreat Trust Fund S Missouri modifications additions to federal adjusted gross income Savings SBG Small Business Guaranty Fees (573) 751 9048 Certificate* SBI Small Business Incubator (573) 526 6708 Certificate* Scale Development (BUILD) Alpha Attach to SCC Missouri Business Modernization and Security Administration or Form SSA 1099 ) SIGNATURE SIGNATURE DATE SPOUSE S SIGNATURE DATE SIGNATUREAMOUNT DUE Single Skip Lines 40 42 if you are not filing an amended return SOCIAL SECURITY NO SOCIAL SECURITY NUMBER SPOUSE (ON A SPOUSE S LAST NAME FIRST NAME INITIAL SPOUSE S SIGNATURE (If filing combined BOTH must sign) SPOUSE S SOCIAL SECURITY NO Subtract Line 13 from Line 8 14 T Missouri modifications subtractions from federal adjusted gross income (Missouri source from Form MO 1040 Line 4) TDC Transportation Development (573) 522 2629 Certificate* Technology (Seed Capital) (573) 522 2790 Original Certificate* Temporary Assistance payments (TA and TANF) Attach a copy of Forms SSA 1099 a letter from the Social Security Administration and Social Services that includes the total amount of assistance received and Employment Security 1099 if applicable 6 These fields are locked To unlock them Click on the "amended" check box on page 1 of this form (top left) This form is available upon request in alternative accessible format(s) THIS FORM MUST BE ATTACHED TO FORM MO 1040 OR FORM MO 1040P Total amount due Add Lines 47 and 48 and enter here Sign below and mail return and payment to: Department of Revenue PO BOX 3370 JEFFERSON CITY MO 65105 3370 Please write your social security number(s) and daytime phone number on your check or money order (U S funds only) Make payable to Missouri Department of Revenue AMOUNT YOU OWE Total Deduction: Enter your total deduction here and on Form MO 1040 Line 18; or on Form MO 1120 Line 7 If you hired more than 30 new employees please print an additional page Trust Fund trust fund boxes to Trust Fund Trust Fund Delivered Meals Family ReliefLead Testing Revenue U MISSOURI INCOME (Missouri sources) Line R plus Line S minus Line T Enter this amount on reverse side Part C Line 1 Under penalties of perjury I declare that I have examined this form and to the best of my knowledge and belief it is true correct and complete Declaration of preparer (other than taxpayer) is based on all information of which he/she has any knowledge As provided in Chapter 143 RSMo a penalty of up to $500 shall be imposed on any individual who files a frivolous return Under penalties of perjury I declare that I have examined this return including accompanying schedules and statements and to the best of my knowledge and belief it is true correct and complete Declaration of preparer (other than taxpayer) is based on all information of which he/she has any knowledge As provided in Chapter 143 RSMo a penalty of up to $500 shall be imposed on any individual who files a frivolous return I also declare under penalties of perjury that I employ no illegal or unauthorized aliens as defined under federal law and that I am not eligible for any tax exemption credit or abatement if I employ such aliens Underpayment of estimated tax penalty Attach Form MO 2210 Enter penalty amount here Veterans Affairs ) WGC Wine and Grape Production (573) 751 9048 Certificate* Alpha Attach to with the preparer or any member of the preparer s firm Workers WORKSHEET FOR LONG TERM CARE INSURANCE DEDUCTION X YES Year With Division of Aging Attach Form MO SCC YES to YES NO to eitherboth YOC Youth Opportunities (573) 526 5417 Certificate* Code Name of Credit and Phone Number Form MO TC You are a both You are a Nonresident You are a Resident you must report both incomes YOURSELF OR