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Additions
1a. State and local income taxes deducted on Federal Form 1120S
or 1065. ......................................................................................... 1a
. 00
1b. Kansas City & St. Louis earnings taxes. Enter Line 1a minus Line 1b
on Line 1 ......................................................................................... 1b . 00 1 . 00
2a. State and local bond interest (except Missouri) ............................. 2a . 00
2b. Related expenses (omit if less than $500).
Enter Line 2a minus Line 2b on Line 2........................................... 2b . 00 2 . 00
3. Partnership Fiduciary Other adjustments ( _______________________) 3 . 00
4. Business interest expense carryforward .......................................................................................... 4 . 00
5. Total Additions - Add Lines 1 through 4 ........................................................................................... 5 . 00
Subtractions
6a. Interest from exempt federal obligations ......................................... 6a . 00
6b. Related expenses (omit if less than $500). Enter Line 6a minus
Line 6b on Line 6 ............................................................................. 6b . 00 6 . 00
Part A - PTE Adjustments
7. Amount of the state income tax refund(s) included in the sum of separately and nonseparately
computed items.. ............................................................................................................................ 7 . 00
8. Federally taxable - Missouri exempt obligations. ............................................................................ 8. 00
9. Partnership Fiduciary Build America and Recovery Zone Bond Interest
Missouri Public-Private Transportation Act Other adjustments (________________) 9 . 00
10. Agricultural Disaster Relief. .............................................................................................................. 10 . 00
11. Disallowed business interest expense .............................................................................................. 11 . 00
12. Total Subtractions - Add Lines 6 through 11..................................................................................... 12 . 00
Select here if the pass-through entity is re-designating the same Affected Business Entity Representative as was used in the
prior tax year.
Under penalties of perjury, I declare that the above information and any attached supplement is true, complete, and correct. The undersigned officer,
manager, or member further declares, under penalties of perjury, that he or she is an officer, manager, or member of the entity for which this return
is filed and that he or she is authorized to make the above election for the entity to become an Affected Business Entity subject to the tax imposed by
Section 143.436, RSMo, for the tax period for which this return is filed.
I authorize the Director of Revenue or delegate to discuss my return and attachments with the preparer or any
member of his or her firm, or if internally prepared, any member of the internal staff ............................................................... Yes No
Signature of Officer, Printed
Manager or Member Name
Signature of Affected Printed
Business Representative Name
Signature Date Signed
Telephone
Number (MM/DD/YY)
Preparer’s Signature Preparer’s FEIN,
(Including Internal Preparer) SSN, or PTIN
Telephone Date Signed
Number (MM/DD/YY)
Did you pay a tax return preparer to complete your return, but the preparer failed to sign the return or provide an Internal
Revenue Service preparer tax identification number? If you marked yes, please insert the preparer’s name, address, and
phone number in the applicable sections of the signature block above . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No
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