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STREET) DOR USE ONLY CITY, STATE, ZIP CODE RETURN THIS FORM WITH CHECK OR MONEY ORDER PAYABLE TO: MISSOURI DEPARTMENT OF REVENUE, P.O. BOX 555, JEFFERSON CITY, MO 65105 0555 * * (Calendar year due April 17, 2012) 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. IF YOU WISH TO RECEIVE A PREPRINTED COUPON BOOK FOR THE REMAINDER OF 2012, PLEASE CHECK THIS BOX. (IT IS NOT.

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