Form Mo 8453 – Fill Out and Use

PART 2 — DECLARATION OF TAXPAYER

Under penalties of perjury, I declare that the information I have provided to my electronic return originator (ERO) or entered via the Internet agree with the amounts shown on the corresponding lines of my 2011 Missouri Individual Income Tax Return and with Part 1 above. To the best of my knowledge and belief, my return is true, correct, and complete. I consent that my return and accompanying schedules and statements, if electronically filed, be sent to the Internal Revenue Service (IRS) by my ERO and by the IRS to the Missouri Department of Revenue. I consent that my return and accompanying schedules and statements, if filed via the Internet, will be retained by me for three years. If I have filed a balance due return, I understand that if the Missouri Department of Revenue does not receive full and timely payment of my tax liability, I will remain liable for the tax liability and applicable interest and additions to tax. If I have filed a joint Federal and State tax return and there is an error on my Federal return, I understand my Missouri return may not be forwarded to the Missouri Department of Revenue. If the processing of my return or refund is delayed, I authorize the Missouri Department of Revenue to disclose to my ERO, practitioner and/or the transmitter the reason(s) for the delay, or when the refund was sent.

I declare, under the penalties of perjury, that I agree to provide the direct deposit information to the Missouri Department of Revenue so my refund check may be deposited into the account specifically designated. I agree the Missouri Department of Revenue will not be liable for misrouting of direct deposit based upon incorrect account information provided by myself or the ERO.

PART 3 — DECLARATION OF ELECTRONIC RETURN ORIGINATOR (ERO) AND PAID PREPARER (IF APPLICABLE)

I declare that I have reviewed the above taxpayer’s return and that the entries on Form MO‑8453 are complete and correct to the best of my knowledge. If I am only a collector, I understand that I am not responsible for reviewing the taxpayer’s return; I declare that Form MO‑8453 accurately reflects the data on the return. I have obtained the taxpayer’s signature on Form MO‑8453 before submitting this return to the Missouri Department of Revenue, have provided the taxpayer with a copy of all forms and information to be filed with the Missouri Department of Revenue and have followed all other requirements described in the Missouri Handbook for Electronic Filers and any requirements specified by the Missouri Department of Revenue. If I am also the Paid Preparer, under penalties of perjury, I declare that I have examined the above taxpayer’s return and accompanying schedules and statements, and to the best of my knowledge and belief, they are true, correct, and complete. This declaration of Paid Preparer is based on all information of which the preparer has any knowledge.

I declare that the direct deposit information transmitted electronically was provided by the taxpayer. I agree I will be liable for reimbursement to the taxpayer or the Missouri Department of Revenue if the direct deposit is misrouted based on this information and cannot be recovered.

Under penalties of perjury, I declare that I have examined the above taxpayer’s return and accompanying schedules and statements, and to the best of my knowledge and belief, they are true, correct, and complete. Declaration of preparer is based on all information of which the preparer has any knowledge.

(11-2011)

INSTRUCTIONS FOR FORM MO-8453

NAME, ADDRESS, AND SOCIAL SECURITY NUMBER — If the taxpayer received an Income Tax Instruction Book, check to see that the information on the label is correct. If all information is correct, use the label on the Form MO-8453. The address must match the address shown on the electronically filed Form MO-1040.

PART 1 — TAX RETURN INFORMATION

Line 1 — Enter the federal adjusted gross income from Form MO-1040, Line 1.

Line 2 — Enter the Missouri tax from Form MO-1040, Line 31.

Line 3 — Enter the amount of refund, if any, from Form MO-1040, Line 46.

Line 4 — Enter the amount you owe, if any, from Form MO-1040, Line 49.

PAYMENT OF BALANCE DUE

Payment of tax due must be made by April 17, 2012, in order to avoid additions to tax and interest.

The taxpayer must submit Form MO-1040V with payment. You may pay online at http://dor.mo.gov/personal/payonline.php or by call- ing (888) 929-0513 to pay with a major credit card.

PART 2 — DECLARATION OF TAXPAYER

Please check appropriate Direct Deposit box.

The Form MO-8453 must be signed by the taxpayer(s).

PART 3 — DECLARATION OF ELECTRONIC RETURN ORIGINATOR (ERO) AND PAID PREPARER

The Form MO-8453 must be signed by the ERO. A paid preparer must sign in the space provided for “Paid Preparer Use Only”, unless the paid preparer is also the ERO, then only the “ERO Use Only” space should be completed and the paid preparer box checked.

Form MO-8453 and supporting documentation (Form W-2s, other state’s returns, etc.) must be retained by the ERO or by the taxpayer if filed over the Internet. DO NOT MAIL!

(11-2011)