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        Missouri Department of Revenue                                        (MM/DD/YY)
      0 0 0  6 6 6 6 0                                       Nonprotested Sales Tax Payment Report
      0 0 0  7 7 7 7 0      2039
                                                                                                                                                     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                                                                                                                                                                                NPRE
                                                                                                                                                             Department Use Only
      1 1 1  4 4 4 4 1 
      1 1 1  5 5 5 5 1                           Owner’s Name                                                         Business Name 
      1 1 1  6 6 6 6 1 
      1 1 1  7 7 7 7 1                           Mailing Address                                                          City                                    State                         Zip Code
                            Company
      1 1 1  8 8 8 8 1 
      1 1 1  9 9 9 9 1                           E-mail Address                                                                                      Phone Number 
      2 2 2  0 0 0 0 2                                                                                                                               (__ __ __) __ __ __ - __ __ __ __
      2 2 2  1 1 1 1 2                             This form is to be used in conjunction with the Sales Tax Protest Payment Affidavit (Form 163). Any nonprotested sales tax 
      2 2 2  2 2 2 2 2                                     payments in a reporting period for which you filed a Protest Payment Affidavit must be reported on this form.
      2 2 2  3 3 3 3 2                                Business Location                Tax Type        Gross Receipts          Adjustments     Taxable Sales         Tax Rate                   Amount of Tax
      2 2 2  4 4 4 4 2                                   (enter below)                                                     Indicate + or -
      2 2 2  5 5 5 5 2                                                         State 3%
      2 2 2  6 6 6 6 2                                                         Conservation 1/8%
      2 2 2  7 7 7 7 2                                                         Education 1%
      2 2 2  8 8 8 8 2 
                                                                               Parks and Soil                                                                          1/10%
      2 2 2  9 9 9 9 2 
      3 3 3  0 0 0 0 3 
      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 
      3 3 3  8 8 8 8 3                                                                                                         Enter total amount of tax from all pages                         1.
                            Protested Payment(s)
      3 3 3  9 9 9 9 3                          Final Return: If this is your final return, enter the close date below and check           Subtract: 2% of Line 1 only if paid by               2.
      4 4 4  0 0 0 0 4                          the reason for closing your account. Missouri law requires any person selling              due date............................................ –
      4 4 4  1 1 1 1 4                          or discontinuing business to make a final sales tax return within 15 days of the           Total amount of tax due:                             3.
      4 4 4  2 2 2 2 4                          sale or closing.                                                                           (Line 1 minus Line 2) ........................       =
      4 4 4  3 3 3 3 4                                                                                                                     Add: Interest for late payment                       4.
      4 4 4  4 4 4 4 4                                                                                                                     (see Instructions) ..............................    +
                                                Date Business Closed (MM/DD/YYYY) __ __ /__ __ /__ __ __ __
      4 4 4  5 5 5 5 4                                                                                                                     Add: additions to tax (5% per month                  5.
                                                                                                                                           late of Line 3, maximum 25%) ..........              +
      4 4 4  6 6 6 6 4                             r     Out of Business     r Sold Business          r  Leased Business
                                                                                                                                           Remit single check for this                          6.
      4 4 4  7 7 7 7 4                                                                                                                     amount: (add Lines 3, 4, 5)...............           =
      4 4 4  8 8 8 8 4 
      4 4 4  9 9 9 9 4                          If you pay by check, you authorize the Department of Revenue to process the check electronically. Any check returned unpaid may be 
      4 4 4  0 0 0 0 4                          presented again electronically.
      5 5 5  1 1 1 1 5                           Under penalties of perjury, I declare that the above information and any attached supplement is true, complete, and correct.
      5 5 5  2 2 2 2 5                           Signature                                                                               Title                     
      5 5 5  3 3 3 3 5 
      5 5 5  4 4 4 4 5      Signature            Printed Name                                                                            Date (MM/DD/YYYY)
      5 5 5  5 5 5 5 5                                                                                                                     __ __ /__ __ /__ __ __ __
      5 5 5  6 6 6 6 5                                                                                                                                                    Form 2039 (Revised 12-2014)
      5 5 5  7 7 7 7 5                                 Taxation Division                        Phone: (573) 526-9938
                           Mail to:
      5 5 5  8 8 8 8 5                                 P.O. Box 3350                            TTY: (800) 735-2966                  Visit http://dor.mo.gov/business/sales/ 
      5 5 5  9 9 9 9 5                                 Jefferson City, MO 65105-3350            Fax: (573) 751-9409                        for additional information.
      5 5 5  0 0 0 0 5                                                                          E-mail:  salesuse@dor.mo.gov 
      6 6 6  1 1 1 1 6 
      6 6 6  2 2 2 2 6                                                                      *14017010001*
      6 6 6  3 3 3 3 6                                                                                      14017010001
      6 6 6  4 4 4 4 6 
      6 6 6  5 5 5 5 6 
      6 6 666 6 6 6 

      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 Page 2
      0 0 0  4 4 4 4 0 
                           This report must be filed in lieu of the Missouri Sales Tax Return to report all nonprotested amounts of taxes in a period 
      0 0 0  5 5 5 5 0 
                           for which you filed a protest payment affidavit. Report only nonprotested payments on this report. Protest payments 
      0 0 0  6 6 6 6 0     must be reported on the Sales Tax Protest Payment Affidavit (Form 163).
      0 0 0  7 7 7 7 0 
      0 0 0  8 8 8 8 0                 Business Location:  Enter the address of each business location for which you have the responsibility of reporting tax.
      0 0 0  9 9 9 9 0 
      1 1 1  0  0  0  0  1             Tax Type:  Listed in this column are the sales taxes administered by the Department of Revenue. It is your responsibility to know 
      1 1 1  1 1 1 1 1                 which taxes you are liable for at each business location. Enter each city or county tax type which is not being protested.
      1 1 1  2 2 2 2 1 
      1 1 1  3 3 3 3 1                 Gross Receipts:  Enter all nonprotested gross receipts by each specific tax type for each business location.
      1 1 1  4 4 4 4 1 
      1 1 1  5 5 5 5 1                 Adjustments:  Enter authorized adjustments. Be sure to indicate plus or minus for each adjustment.
      1 1 1  6 6 6 6 1 
                                       Taxable Sales:  Complete taxable sales for each entry.
      1 1 1  7 7 7 7 1 
      1 1 1  8 8 8 8 1 
                                                Gross receipts (+) or (–) adjustments = taxable sales
      1 1 1  9 9 9 9 1 
      2 2 2  0 0 0 0 2                 Tax Rate:  The state, conservation, education and parks and soil sales tax rates are preprinted in this column. If you are subject 
      2 2 2  1 1 1 1 2                 to city and county taxes, enter the local sales tax rate for each city and county tax type.
      2 2 2  2 2 2 2 2 
                           Instructions
      2 2 2  3 3 3 3 2                 Amount of Tax:  multiply taxable sales by the tax rate of each specific tax.
      2 2 2  4 4 4 4 2 
      2 2 2  5 5 5 5 2                 Line 1 — total amount of tax:  compute total amount of taxes shown in the amount of tax column from pages 1 and 3(if applicable).
      2 2 2  6 6 6 6 2 
      2 2 2  7 7 7 7 2                 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.
      2 2 2  8 8 8 8 2 
      2 2 2  9 9 9 9 2                 Line 3 — follow instructions shown on front of form.
      3 3 3  0 0 0 0 3 
      3 3 3  1 1 1 1 3                 Line 4 — interest for late payment:  If tax is not paid by the due date, multiply Line 3 by the annual percentage rate and then 
      3 3 3  2 2 2 2 3                 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 
      3 3 3  3 3 3 3 3                 change each year. The annual percentage rate can be obtained from our website at http://dor.mo.gov/intrates.php.  
      3 3 3  4 4 4 4 3 
      3 3 3  5 5 5 5 3                 Lines 5 and 6 — Follow instructions shown on front of form.
      3 3 3  6 6 6 6 3 
      3 3 3  7 7 7 7 3 
      3 3 3  8 8 8 8 3 
      3 3 3  9 9 9 9 3 
      4 4 4  0 0 0 0 4 
      4 4 4  1 1 1 1 4 
      4 4 4  2 2 2 2 4 
      4 4 4  3 3 3 3 4 
      4 4 4  4 4 4 4 4 
      4 4 4  5 5 5 5 4 
      4 4 4  6 6 6 6 4 
      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 
      5 5 5  1 1 1 1 5 
      5 5 5  2 2 2 2 5 
      5 5 5  3 3 3 3 5 
      5 5 5  4 4 4 4 5 
      5 5 5  5 5 5 5 5 
      5 5 5  6 6 6 6 5 
      5 5 5  7 7 7 7 5 
      5 5 5  8 8 8 8 5 
      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                                                           *14000000001*
      6 6 6  3 3 3 3 6                                                                              14000000001
      6 6 6  4 4 4 4 6                                                                                                                             Form 2039 (Revised 12-2014)
      6 6 6  5 5 5 5 6 
      6 6 666 6 6 6 

      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 Page 3
      0 0 0  4 4 4 4 0     This schedule is to be used only if the space provided on page 1 of the report is insufficient to report all non-protest payments. To 
      0 0 0  5 5 5 5 0     complete this page, refer to instructions on page 2.
      0 0 0  6 6 6 6 0              Business Location             Tax Type        Gross Receipts   Adjustments    Taxable Sales         Tax Rate    Amount of Tax
      0 0 0  7 7 7 7 0                                                                             Indicate + or -
      0 0 0  8 8 8 8 0                                      State 3%
      0 0 0  9 9 9 9 0                                      Conservation 1/8%
      1 1 1  0  0  0  0  1                                  Education 1%
      1 1 1  1 1 1 1 1                                      Parks and Soil                                                              1/10%
      1 1 1  2 2 2 2 1 
      1 1 1  3 3 3 3 1 
      1 1 1  4 4 4 4 1 
      1 1 1  5 5 5 5 1 
      1 1 1  6 6 6 6 1 
      1 1 1  7 7 7 7 1 
      1 1 1  8 8 8 8 1 
      1 1 1  9 9 9 9 1 
      2 2 2  0 0 0 0 2 
      2 2 2  1 1 1 1 2 
      2 2 2  2 2 2 2 2 
      2 2 2  3 3 3 3 2 
      2 2 2  4 4 4 4 2                                      State 3%
      2 2 2  5 5 5 5 2                                      Conservation 1/8%
      2 2 2  6 6 6 6 2                                      Education 1%
      2 2 2  7 7 7 7 2                                      Parks and Soil                                                              1/10%
      2 2 2  8 8 8 8 2 
      2 2 2  9 9 9 9 2 
      3 3 3  0 0 0 0 3 
      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     Protested Payment(s)
      3 3 3  7 7 7 7 3 
      3 3 3  8 8 8 8 3 
      3 3 3  9 9 9 9 3 
      4 4 4  0 0 0 0 4                                      State 3%
      4 4 4  1 1 1 1 4                                      Conservation 1/8%
      4 4 4  2 2 2 2 4                                      Education 1%
      4 4 4  3 3 3 3 4                                      Parks and Soil                                                              1/10%
      4 4 4  4 4 4 4 4 
      4 4 4  5 5 5 5 4 
      4 4 4  6 6 6 6 4 
      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 
      5 5 5  1 1 1 1 5 
      5 5 5  2 2 2 2 5 
      5 5 5  3 3 3 3 5 
      5 5 5  4 4 4 4 5 
      5 5 5  5 5 5 5 5 
      5 5 5  6 6 6 6 5 
      5 5 5  7 7 7 7 5 
      5 5 5  8 8 8 8 5 
      5 5 5  9 9 9 9 5 
      5 5 5  0 0 0 0 5                                                                                        Enter total here and on Page 1
      6 6 6  1 1 1 1 6                                                                                                                      Form 2039 (Revised 12-2014)
      6 6 6  2 2 2 2 6                                                     *14017020001*
      6 6 6  3 3 3 3 6                                                                  14017020001
      6 6 6  4 4 4 4 6 
      6 6 6  5 5 5 5 6 
      6 6 666 6 6 6