0 0 0 1 1 1 1 0 
0 0 0 0 0 0 0 0 0 0 0 1 1 1 1 1 1 1 1 1 1 2 2 2 2 2 2 2 2 2 2 3 3 3 3 3 3 3 3 3 3 4 4 4 4 4 4 4 4 4 4 5 5 5 5 5 5 5 5 5 5 6 6 6 6 6 6 6 6 6 6 7 7 7 7 7 7 7 7 7 7 8 8 8 8 8 80 0 0 0 0 0 0 0 1 1 1 1 1 1 1 1 1 1 2 2 2 2 2 2 2 2 2 2 3 3 3 3 3 3 3 3 3 3 4 4 4 4 4 4 4 4 4 4 5 5 5 5 5 5 5 5 5 5 6 6 6 6 6 6 6 6 6 6 7 7 7 7 7 7 7 7 7 7 8 8 8 8 8 80 0 0 0 0 0 0 0 1 1 1 1 1 1 1 1 1 1 2 2 2 2 2 2 2 2 2 2 3 3 3 3 3 3 3 3 3 3 4 4 4 4 4 4 4 4 4 4 5 5 5 5 5 5 5 5 5 5 6 6 6 6 6 6 6 6 6 6 7 7 7 7 7 7 7 7 7 7 8 8 8 8 8 80 0 0 0 0 0 0 0 1 1 1 1 1 1 1 1 1 1 2 2 2 2 2 2 2 2 2 2 3 3 3 3 3 3 3 3 3 3 4 4 4 4 4 4 4 4 4 4 5 5 5 5 5 5 5 5 5 5 6 6 6 6 6 6 6 6 6 6 7 7 7 7 7 7 7 7 7 7 8 8 8 8 8 80 
1 1 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 52 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 52 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 52 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 51 
      0 0 0  4 4 4 4 0                                                                                                       Department Use Only
      0 0 0  5 5 5 5 0                 Form                                                                                  (MM/DD/YY)
      0 0 0  6 6 6 6 0                              Use Tax Protest Payment Report
      0 0 0  7 7 7 7 0         2041                                                                                                              Reporting Period
      0 0 0  8 8 8 8 0                                                                                                                           (MM/YY)
      0 0 0  9 9 9 9 0 
      1 1 1  0  0  0  0  1 Missouri Tax I.D.                                                                      Federal Employer
      1 1 1  1 1 1 1 1     Number                                                                                 I.D. Number
      1 1 1  2 2 2 2 1 
      1 1 1  3 3 3 3 1     Case Number
      1 1 1  4 4 4 4 1     (if applicable)
      1 1 1  5 5 5 5 1 
                                                                                                                                                        PPRE
      1 1 1  6 6 6 6 1                  Type of Tax Protested    r Consumer’s       Use Tax   r Vendor’s Use Tax                                FPRE
      1 1 1  7 7 7 7 1 
                                       Owner’s Name                                                               Business Name 
      1 1 1  8 8 8 8 1 
      1 1 1  9 9 9 9 1 
                                       Mailing Address                                                              City                                    State        ZIP Code
      2 2 2  0 0 0 0 2         Business
      2 2 2  1 1 1 1 2 
                                       E-mail Address                                                                                         Phone Number 
      2 2 2  2 2 2 2 2 
                                                                                                                                               (__ __ __) __ __ __ - __ __ __ __
      2 2 2  3 3 3 3 2 
      2 2 2  4 4 4 4 2 
      2 2 2  5 5 5 5 2                       This form is to be used for filing a use tax protest payment in compliance with Section 144.700, RSMo.

      2 2 2  6 6 6 6 2                   Vendor’s Use Tax                  Tax Type          Gross Receipts             Adjustments      Taxable Sales         Tax Rate                    Amount of Tax
      2 2 2  7 7 7 7 2 
                                       Business Location (Enter below)  State Use                                                                               3%
      2 2 2  8 8 8 8 2 
                                                                        Conservation 1/8%
      2 2 2  9 9 9 9 2 
                                                                        Education 1%
      3 3 3  0 0 0 0 3 
                                                                        Parks and Soil                                                                         1/10%
      3 3 3  1 1 1 1 3 
      3 3 3  2 2 2 2 3 
      3 3 3  3 3 3 3 3 
      3 3 3  4 4 4 4 3 
      3 3 3  5 5 5 5 3 
      3 3 3  6 6 6 6 3 
      3 3 3  7 7 7 7 3                 Vendor’s Use Totals                                              Enter total amount of vendor’s use tax from all pages                            1.
      3 3 3  8 8 8 8 3                                                                                                                       Subtract 2% timely payment                  2.
                                                                                                                                             allowance (If applicable)                   –
      3 3 3  9 9 9 9 3                                                                                                                              Vendor’s use tax due                 3.
      4 4 4  0 0 0 0 4                                                                                                                              (Line 1 minus Line 2)                =
      4 4 4  1 1 1 1 4                   Consumer’s Use Tax                Tax Type                     Taxable Purchases                    Tax Rate                  Amount of Tax
      4 4 4  2 2 2 2 4                  Business Location (Enter below) State Use                                                             3%
      4 4 4  3 3 3 3 4                                                  Conservation 1/8%
      4 4 4  4 4 4 4 4                                                  Education 1%
      4 4 4  5 5 5 5 4                                                  Parks and Soil                                                       1/10%
      4 4 4  6 6 6 6 4         Protested Amount(s)
      4 4 4  7 7 7 7 4 
      4 4 4  8 8 8 8 4 
      4 4 4  9 9 9 9 4 
      4 4 4  0 0 0 0 4                 Consumer’s Use Totals                                            Enter total amount of consumer’s use tax from all pages                          4.
      5 5 5  1 1 1 1 5                                                                                                              Total use tax due:                                   5.
      5 5 5  2 2 2 2 5                                                                                                              (add Lines 3 and 4)............................. =
      5 5 5  3 3 3 3 5                 Final Return: If this is your final return, enter the close date below and select the reason Add:  Interest for late payment                      6.
                                       for closing your account. Missouri law requires any person selling or discontinuing          (see instructions) ................................ +
      5 5 5  4 4 4 4 5                 business to make a final use tax return within 15 days of the purchase or closing.           Add:  Additions to tax (5% per month                 7.
      5 5 5  5 5 5 5 5                                                                                                              late of Line 5, maximum 25%) ...........             +
      5 5 5  6 6 6 6 5                 Date Business Closed (MM/DD/YYYY)            __ __ /__ __ /__ __ __ __                       Subtract:  Approved credit                           8.
                                                                                                                                    (attach credit memorandum) ..............            –
      5 5 5  7 7 7 7 5                   r      Out of Business      r     Sold Business      r    Leased Business                  Remit single check                                   9.
      5 5 5  8 8 8 8 5                                                                                                              for this amount: ................................... =
      5 5 5  9 9 9 9 5 
      5 5 5  0 0 0 0 5 
      6 6 6  1 1 1 1 6 
      6 6 6  2 2 2 2 6                                                                 *14019010001*
      6 6 6  3 3 3 3 6                                                                                  14019010001                                                 Form 2041 (Revised 02-2020)
      6 6 6  4 4 4 4 6 
      6 6 6  5 5 5 5 6 
      6 6 666 6 6 6 

                                                                                                                                                                                       Page 2

                  Reason for Protest

                                                       Section 144.700, RSMo, must be complied with or the protest payment will be deposited to General Revenue.
                                                       Embosser or black ink rubber stamp seal Subscribed and sworn before me, this
                                                                                                                        day of                                                     year
                                                                                               State     County (or City of St. Louis) My Commission Expires (MM/DD/YYYY)
                                                                                                                                       __ __ /__ __ /__ __ __ __
                                                                                               Notary Public Signature   

                                    Notary Information                                         Notary Public Name (Typed or Printed) 

                                                       Disposition                   Reason                                                           Date (MM/DD/YYYY)
                                                                                                                                                      __ __ /__ __ /__ __ __ __

                  Department Use Only                  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.

                                                       Under penalties of perjury, I declare that the above information and any attached supplement is true, complete, and correct.
                                                       Signature                                                                     Title             

 Signature                                             Printed Name                                                                  Date (MM/DD/YYYY)
                                                                                                                                     __ __ /__ __ /__ __ __ __

                                                                                                                                                              Form 2041 (Revised 02-2020)
Mail to:                                               Taxation Division                       Phone: (573) 526-9938    Visit http://dor.mo.gov/business/sales/ 
                                                       P.O. Box 3350                           TTY: (800) 735-2966                   for additional information.
                                                       Jefferson City, MO 65105-3350           Fax: (573) 751-9409
                                                                                               E-mail:  salesrefund@dor.mo.gov 

                                                                                               *14019020001*
                                                                                                         14019020001

Page 3
This schedule is to be used only if the space provided on page 1 of the Protest Report is insufficient to report all protest payments.
To complete Schedule A, refer to instructions on page 4.
Business Location Tax Type Gross Receipts Adjustments Taxable Sales Tax Amount of Tax
Indicate + or – ) Rate (%)
State 3%
Conservation 1/8%
Education 1%
Parks and Soil 1/10%

Business Location Tax Type Gross Receipts Adjustments Taxable Sales Tax Amount of Tax
Indicate + or – ) Rate (%)
State 3%
Conservation 1/8%
Education 1%
Parks and Soil 1/10%

Schedule(s) A

Business Location Tax Type Gross Receipts Adjustments Taxable Sales Tax Amount of Tax
Indicate + or – ) Rate (%)
State 3%
Conservation 1/8%
Education 1%
Parks and Soil 1/10%

Enter total amount of tax
Enter total amount on page 1

*14019020001*
14019030001 Form 2041 (Revised 02-2020)

Business Location:  Enter the address of each business location for which you are reporting a protest payment. Attach additional copies of this 
form in order to report multiple locations.
Tax Type:  The state, conservation, education, and parks and soil taxes are preprinted in this column. Enter each city or county tax type which is 
being protested.  It is your responsibility to know which taxes you are liable for at each business location.
Vendor’s Use Tax
Gross Receipts:  Enter protested amount of gross receipts by each specific tax type for each business location.
Adjustments:  Enter authorized adjustments. Be sure to indicate plus or minus for each adjustment.
Taxable Sales:  Compute taxable sales for each entry.
 Gross receipts (+) or (–) adjustments = taxable sales
Tax Rate:  The state, conservation, education, and parks and soil tax rates are preprinted in this column. If you are protesting a city or county tax 
payment, enter the local use tax rate for each city or county tax type.
Amount of Tax:  Multiply taxable sales by the tax rate of each specific tax type.
Line 1 — total amount of tax:  Compute total amount of taxes shown in the amount of tax column.
Line 2 — timely payment allowance:  If you file and pay on or before the due date, enter 2% of the amount shown on Line 1.
Line 3 — vendor’s use tax due:  Subtract Line 2 from Line 1 and enter remainder.
Instructions
Consumer’s Use Tax:  You must pay consumer’s use tax on tangible personal property stored, used, or consumed in Missouri unless you paid 
tax to the seller or the property is exempt from tax. A purchaser is required to file a use tax return if the cumulative purchases subject to use tax 
exceed $2,000 in a calendar year.
Taxable Purchases:  Enter protested amount of taxable purchases by each specific tax type for each business location.
Tax Rate:  The state, conservation, education, and parks and soil tax rates are preprinted in this column. If you are protesting a city or county tax 
payment, enter the local use tax rate for each city or county tax type.
Amount of Tax:  Multiply taxable purchases by the tax rate of each specific tax type.
Line 4 — total amount of tax:  Compute total amount of taxes shown in the amount of tax column.
Line 5 — follow instructions shown on front of form.
Line 6 — interest for late payment:  If tax is not paid by the due date, multiply Line 5 by the annual percentage rate and then multiply this amount 
by the number of days late divided by 365 (or 366 in a leap year). The annual percentage rate is subject to change each year. The annual 
percentage rate can be obtained from our website at http://dor.mo.gov/intrates.php.
Lines 7 and 8 — Follow instructions shown on front of form.

*14000000001*
14000000001 Form 2041 (Revised 02-2020)