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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 07-2013)
 Mail to:  Taxation Division                                                             Phone: (573) 751-2326   
                                                                                                                    Visit 
                                                        P.O. Box 898                     Fax:  (573) 522-1721             http://dor.mo.gov/business/finance/ 
                                                                                                                          for additional information.
                                                        Jefferson City, MO 65105-0898    E-mail: fit@dor.mo.gov