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                                            Form
                                                         Application for Financial Institution Tax Credit or Refund
 1141

                                                                               Financial Institution Type:
 r  Refund                                               r  Credit             r Bank  r Credit Institution   r Credit Union                                                            r Savings and Loan
 Name of Financial Institution

 Mailing Address                                                                                     City                                                                               State ZIP Code

                                                       1.  For taxable year__________ based on the calendar year income period ___________.

                                                       2. Amount of tax paid........................................................................................................... 2
                                                         Dates of payments: ________________________________________________
                                            Information
 Credit or Refund                                      3.  Amount to be credited or refunded ..................................................................................         3

                      Reason for Overpayment

                                                        Under penalties of perjury, I declare the information I have provided and any attached supplement is true, complete, and correct.
                                                       Signature of Officer                          Title                                                                                    Date (MM/DD/YYYY)
                                                                                                                                                                                              __ __ / __ __ / __ __ __ __
                  Signature                            Printed Name of Officer                       E-mail Address of Officer

                                                                                                                                                                                              Form 1141 (Revised 02-2020)
Mail to:   Taxation Division                                                           E-mail:  fit@dor.mo.gov 
                                                         P.O. Box 898                  Visit dor.mo.gov/taxation/business/tax-types/finance/ for additional information.
                                                         Jefferson City, MO 65105-0898
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 Phone:                                                 (573) 751-2326                 If yes, visit dor.mo.gov/military/ to see the services and benefits we offer to all eligible 
 Fax:                                                   (573) 522-1762                 military individuals. A list of all state agency resources and benefits can be found at 
                                                                                       veteranbenefits.mo.gov/state-benefits/.