2022 Tax Return

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Form 8879 IRS e-file Signature Authorization
(Rev. January 2021) OMB No. 1545-0074
a
ERO must obtain and retain completed Form 8879.
Department of the Treasury
a Go to www.irs.gov/Form8879 for the latest information.
Internal Revenue Service

F
Submission Identification Number (SID)
Taxpayer’s name Social security number

SHAUNA R DAVIS 495-17-2822

Spouse’s name Spouse’s social security number

Part I Tax Return Information — Tax Year Ending December 31, 2022 (Enter year you are authorizing.)
Enter whole dollars only on lines 1 through 5.
Note: Form 1040-SS filers use line 4 only. Leave lines 1, 2, 3, and 5 blank.
1 Adjusted gross income . . . . . . . . . . . . . . . . . . . . . . . . . . 1 17760
2 Total tax . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 483
3 Federal income tax withheld from Form(s) W-2 and Form(s) 1099 . . . . . . . . . . . . . 3 820
4 Amount you want refunded to you . . . . . . . . . . . . . . . . . . . . . . 4 337
5 Amount you owe . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Part II Taxpayer Declaration and Signature Authorization (Be sure you get and keep a copy of your return)
Under penalties of perjury, I declare that I have examined a copy of the income tax return (original or amended) I am now authorizing, and to the best of
my knowledge and belief, it is true, correct, and complete. I further declare that the amounts in Part I above are the amounts from the income tax
return (original or amended) I am now authorizing. I consent to allow my intermediate service provider, transmitter, or electronic return originator (ERO)
to send my return to the IRS and to receive from the IRS (a) an acknowledgement of receipt or reason for rejection of the transmission, (b) the reason
for any delay in processing the return or refund, and (c) the date of any refund. If applicable, I authorize the U.S. Treasury and its designated Financial
Agent to initiate an ACH electronic funds withdrawal (direct debit) entry to the financial institution account indicated in the tax preparation software for
payment of my federal taxes owed on this return and/or a payment of estimated tax, and the financial institution to debit the entry to this account. This
authorization is to remain in full force and effect until I notify the U.S. Treasury Financial Agent to terminate the authorization. To revoke (cancel) a
payment, I must contact the U.S. Treasury Financial Agent at 1-888-353-4537. Payment cancellation requests must be received no later than 2
business days prior to the payment (settlement) date. I also authorize the financial institutions involved in the processing of the electronic payment of
taxes to receive confidential information necessary to answer inquiries and resolve issues related to the payment. I further acknowledge that the
personal identification number (PIN) below is my signature for the income tax return (original or amended) I am now authorizing and, if applicable, my
Electronic Funds Withdrawal Consent.
Taxpayer’s PIN: check one box only
0 0 0 0 0
I authorize to enter or generate my PIN as my
Enter five digits, but
ERO firm name don’t enter all zeros
signature on the income tax return (original or amended) I am now authorizing.
X I will enter my PIN as my signature on the income tax return (original or amended) I am now authorizing. Check this box only
if you are entering your own PIN and your return is filed using the Practitioner PIN method. The ERO must complete Part III
below.
Your signature a Date a

Spouse’s PIN: check one box only

I authorize to enter or generate my PIN as my
ERO firm name Enter five digits, but
signature on the income tax return (original or amended) I am now authorizing. don’t enter all zeros

I will enter my PIN as my signature on the income tax return (original or amended) I am now authorizing. Check this box only
if you are entering your own PIN and your return is filed using the Practitioner PIN method. The ERO must complete Part III
below.

Spouse’s signature a Date a

Practitioner PIN Method Returns Only—continue below
Part III Certification and Authentication — Practitioner PIN Method Only
ERO’s EFIN/PIN. Enter your six-digit EFIN followed by your five-digit self-selected PIN.
Don’t enter all zeros

I certify that the above numeric entry is my PIN, which is my signature for the electronic individual income tax return (original or amended) I am now
authorized to file for tax year indicated above for the taxpayer(s) indicated above. I confirm that I am submitting this return in accordance with the
requirements of the Practitioner PIN method and Pub. 1345, Handbook for Authorized IRS e-file Providers of Individual Income Tax Returns.

ERO’s signature a TAXSLAYER 03/26/2024 Date a

ERO Must Retain This Form — See Instructions
Don’t Submit This Form to the IRS Unless Requested To Do So
For Paperwork Reduction Act Notice, see your tax return instructions. b
Form 8879 (Rev. 01-2021)
QNA
 1040 U.S. Individual Income Tax Return 2022
Form Department of the Treasury—Internal Revenue Service

OMB No. 1545-0074 IRS Use Only—Do not write or staple in this space.

Filing Status x Single Married filing jointly Married filing separately (MFS) Head of household (HOH)
Qualifying surviving
Check only spouse (QSS)
one box. If you checked the MFS box, enter the name of your spouse. If you checked the HOH or QSS box, enter the child’s name if the qualifying
person is a child but not your dependent:
Your first name and middle initial Last name Your social security number
SHAUNA R DAVIS 495-17-2822
If joint return, spouse’s first name and middle initial Last name Spouse’s social security number

Home address (number and street). If you have a P.O. box, see instructions. Apt. no. Presidential Election Campaign
511 CHARLES PL Check here if you, or your
spouse if filing jointly, want $3
City, town, or post office. If you have a foreign address, also complete spaces below. State ZIP code
to go to this fund. Checking a
O FALLON MO 63366 box below will not change
Foreign country name Foreign province/state/county Foreign postal code your tax or refund.
You Spouse

Digital At any time during 2022, did you: (a) receive (as a reward, award, or payment for property or services); or (b) sell,
Assets exchange, gift, or otherwise dispose of a digital asset (or a financial interest in a digital asset)? (See instructions.) Yes X No
Standard Someone can claim: You as a dependent Your spouse as a dependent
Deduction Spouse itemizes on a separate return or you were a dual-status alien

Age/Blindness You: Were born before January 2, 1958 Are blind Spouse: Was born before January 2, 1958 Is blind
Dependents (see instructions): (2) Social security (3) Relationship (4) Check the box if qualifies for (see instructions):
(1) First name Last name number to you Child tax credit Credit for other dependents
If more
than four
dependents,
see instructions
and check
here . .
1a Total amount from Form(s) W-2, box 1 (see instructions) . . . . . . . . . . . . . 1a 17760
Income
b Household employee wages not reported on Form(s) W-2 . . . . . . . . . . . . . 1b
Attach Form(s) c Tip income not reported on line 1a (see instructions) . . . . . . . . . . . . . . 1c
W-2 here. Also
attach Forms d Medicaid waiver payments not reported on Form(s) W-2 (see instructions) . . . . . . . . 1d
W-2G and e Taxable dependent care benefits from Form 2441, line 26 . . . . . . . . . . . . 1e
1099-R if tax
was withheld. f Employer-provided adoption benefits from Form 8839, line 29 . . . . . . . . . . . 1f
If you did not g Wages from Form 8919, line 6 . . . . . . . . . . . . . . . . . . . . . 1g
get a Form h Other earned income (see instructions) . . . . . . . . . . . . . . . . . . 1h
W-2, see
instructions.
i Nontaxable combat pay election (see instructions) . . . . . . . 1i
z Add lines 1a through 1h . . . . . . . . . . . . . . . . . . . . . . 1z 17760
Attach Sch. B 2a Tax-exempt interest . . . 2a b Taxable interest . . . . . 2b
if required. 3a Qualified dividends . . . 3a b Ordinary dividends . . . . . 3b
4a IRA distributions . . . . 4a b Taxable amount . . . . . . 4b
Standard 5a Pensions and annuities . . 5a b Taxable amount . . . . . . 5b
Deduction for—
6a Social security benefits . . 6a b Taxable amount . . . . . . 6b
• Single or
Married filing c If you elect to use the lump-sum election method, check here (see instructions) . . . . .
separately,
$12,950 7 Capital gain or (loss). Attach Schedule D if required. If not required, check here . . . . . 7
• Married filing 8 Other income from Schedule 1, line 10 . . . . . . . . . . . . . . . . . . 8
jointly or
Qualifying 9 Add lines 1z, 2b, 3b, 4b, 5b, 6b, 7, and 8. This is your total income . . . . . . . . . . 9 17760
surviving spouse,
$25,900
10 Adjustments to income from Schedule 1, line 26 . . . . . . . . . . . . . . . 10
• Head of 11 Subtract line 10 from line 9. This is your adjusted gross income . . . . . . . . . . 11 17760
household,
$19,400 12 Standard deduction or itemized deductions (from Schedule A) . . . . . . . . . . 12 12950
• If you checked 13 Qualified business income deduction from Form 8995 or Form 8995-A . . . . . . . . . 13
any box under
Standard 14 Add lines 12 and 13 . . . . . . . . . . . . . . . . . . . . . . . . 14 12950
Deduction, 15 Subtract line 14 from line 11. If zero or less, enter -0-. This is your taxable income . . . . . 4810
see instructions.
15

For Disclosure, Privacy Act, and Paperwork Reduction Act Notice, see separate instructions. Form 1040 (2022)
QNA
 DAVIS 495-17-2822
Form 1040 (2022) Page 2

Tax and 16 Tax (see instructions). Check if any from Form(s): 1 8814 2 4972 3 . . 16 483
Credits 17 Amount from Schedule 2, line 3 . . . . . . . . . . . . . . . . . . . . 17
18 Add lines 16 and 17 . . . . . . . . . . . . . . . . . . . . . . . . 18 483
19 Child tax credit or credit for other dependents from Schedule 8812 . . . . . . . . . . 19
20 Amount from Schedule 3, line 8 . . . . . . . . . . . . . . . . . . . . 20
21 Add lines 19 and 20 . . . . . . . . . . . . . . . . . . . . . . . . 21
22 Subtract line 21 from line 18. If zero or less, enter -0- . . . . . . . . . . . . . . 22 483
23 Other taxes, including self-employment tax, from Schedule 2, line 21 . . . . . . . . . 23 0
24 Add lines 22 and 23. This is your total tax . . . . . . . . . . . . . . . . . 24 483
Payments 25 Federal income tax withheld from:
a Form(s) W-2 . . . . . . . . . . . . . . . . . . 25a 820
b Form(s) 1099 . . . . . . . . . . . . . . . . . . 25b
c Other forms (see instructions) . . . . . . . . . . . . . 25c
d Add lines 25a through 25c . . . . . . . . . . . . . . . . . . . . . . 25d 820
26 2022 estimated tax payments and amount applied from 2021 return . . . . . . . . . . 26
If you have a
qualifying child, 27 Earned income credit (EIC) . . . . . . . . . . . . . . 27
attach Sch. EIC.
28 Additional child tax credit from Schedule 8812 . . . . . . . . 28
29 American opportunity credit from Form 8863, line 8 . . . . . . . 29
30 Reserved for future use . . . . . . . . . . . . . . . 30
31 Amount from Schedule 3, line 15 . . . . . . . . . . . . 31
32 Add lines 27, 28, 29, and 31. These are your total other payments and refundable credits . . 32
33 Add lines 25d, 26, and 32. These are your total payments . . . . . . . . . . . . 33 820
Refund 34 If line 33 is more than line 24, subtract line 24 from line 33. This is the amount you overpaid . . 34 337
35a Amount of line 34 you want refunded to you. If Form 8888 is attached, check here . . . . 35a 337
Direct deposit? b Routing number X X X X X X X X X c Type: Checking Savings
See instructions.
d Account number X X X X X X X X X X X X X X X X X
36 Amount of line 34 you want applied to your 2023 estimated tax . . . 36
Amount 37 Subtract line 33 from line 24. This is the amount you owe.
You Owe For details on how to pay, go to www.irs.gov/Payments or see instructions . . . . . . . . 37
38 Estimated tax penalty (see instructions) . . . . . . . . . . 38
Third Party Do you want to allow another person to discuss this return with the IRS? See
Designee instructions . . . . . . . . . . . . . . . . . . . . . Yes. Complete below. No
Designee’s Phone Personal identification
name no. number (PIN)
Under penalties of perjury, I declare that I have examined this return and accompanying schedules and statements, and to the best of my knowledge and
Sign belief, they are true, correct, and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge.
Here Your signature Date Your occupation If the IRS sent you an Identity
Protection PIN, enter it here
Joint return? (see inst.)
CUSTODIAN
See instructions. Spouse’s signature. If a joint return, both must sign. Date Spouse’s occupation If the IRS sent your spouse an
Keep a copy for Identity Protection PIN, enter it here
your records. (see inst.)

Phone no. (636) 293-4180 Email address HXNEYYCXMBS@GMAIL.COM

Preparer’s name Preparer’s signature Date PTIN Check if:
Paid Self-employed
Preparer
Firm’s name Phone no.
Use Only
Firm’s address Firm’s EIN
Go to www.irs.gov/Form1040 for instructions and the latest information. Form 1040 (2022)
QNA
 Form
MO-1040 2022 Individual Income
Tax Return - Long Form

For Calendar Year January 1 - December 31, 2022

Print in BLACK ink only and DO NOT STAPLE.

Amended Return Composite Return

(For use by S corporations or Partnerships)
Federal Extension - Select this box if you have an approved federal extension. Attach a copy Federal Extension (Form 4868).

If filing a fiscal year return enter the beginning and ending dates here.
Fiscal Year Beginning (MM/DD/YY) Fiscal Year Ending (MM/DD/YY) Vendor Code Department Use Only

038
Filing Status

X Single Claimed as a Married Filing Married Filing Head of Qualifying

Dependent Combined Separately Household Widow(er)

Age 62 through 64 Age 65 or Older Blind 100% Disabled Non-Obligated Spouse

Yourself Spouse Yourself Spouse Yourself Spouse Yourself Spouse Yourself Spouse

Deceased Deceased
Social Security Number in 2022 Spouse’s Social Security Number in 2022

4 9 5 -1 7 -2 8 2 2 - -
First Name M.I. Last Name Suffix
Name

SHAUNA R DAVIS
Spouse’s First Name M.I. Spouse’s Last Name Suffix

In Care Of Name (Attorney, Executor, Personal Representative, etc.)

Present Address (Include Apartment Number or Rural Route)

511 CHARLES PL
Address

City, Town, or Post Office State ZIP Code

_
O FALLON MO 63366
County of Residence

STCH

You may contribute to any one or all of the trust funds on Line 50. See pages 11-12 of the instructions for more trust fund information.

Kansas
Workers LEAD General City
Revenue Regional
Law Soldiers
Elderly Home Missouri Workers’ Childhood Missouri Military General Enforcement
Children’s Veterans Delivered Meals National Guard Memorial Lead Testing Family Relief Organ Donor Memorial
Missouri Medal Revenue Program Fund Memorial Military Museum
of Honor Fund Trust Fund Trust Fund Trust Fund Trust Fund Fund Fund Fund Fund Foundation Fund in St. Louis Fund

MO-1040 Page 1
 Yourself (Y) Spouse (S)
1. Federal adjusted gross income from federal return
(see worksheet on page 7 of the instructions) . . . . . . . . . . . . . 1Y 17760 . 00 1S . 00

2. Total additions (from Form MO-A, Part 1, Line 7) . . . . . . . . . . 2Y . 00 2S . 00

3. Total income - Add Lines 1 and 2. . . . . . . . . . . . . . . . . . . . . . . 3Y 17760 . 00 3S . 00

Income

4. Total subtractions (from Form MO-A, Part 1, Line 18) . . . . . . . 4Y . 00 4S . 00

5. Missouri adjusted gross income - Subtract Line 4 from Line 3. . 5Y 17760 . 00 5S . 00

6. Total Missouri adjusted gross income - Add columns 5Y and 5S . . . . . . . . . . . 6 17760 . 00

7. Income percentages - Divide columns 5Y and 5S by total on

Line 6. (Must equal 100%) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7Y 100 % 7S %
8. Pension, Social Security and Social Security Disability exemption (from Form MO-A, Part 3,
Section D) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 . 00

9. Tax from federal return . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 483 . 00

10. Other tax from federal return. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 . 00

11. Total tax from federal return. Do not enter federal income tax withheld. 11 483 . 00

12. Federal tax percentage – Enter the percentage based on your

Missouri Adjusted Gross Income, Line 6. Use the chart below to
find your percentage . . . . . . . . . . . . . . . . . . . . . . . . 12 35.0 %

Missouri Adjusted Gross Income Range, Line 6: Federal Tax Percentage:

$25,000 or less ........................................................................ 35%
$25,001 to $50,000.................................................................. 25%
Exemptions and Deductions

$50,001 to $100,000................................................................15%
$100,001 to $125,000............................................................... 5%
$125,001 or more ..................................................................... 0%

13. Federal income tax deduction – Multiply Line 11 by the percentage on Line 12. Enter this
amount not to exceed $5,000 for an individual or $10,000 for combined filers. . . . . . . . . . . . . . . 13 169 . 00
14. Missouri standard deduction or itemized deductions. (If itemizing, See Form MO-A, Part 2)
• Single or Married Filing Separate-$12,950 • Head of Household-$19,400
• Married Filing Combined or Qualifying Widow(er)-$25,900 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 12950 . 00

15. Additional Exemption for Head of Household and Qualified Widow(er) . . . . . . . . . . . . . . . . . . . . 15 . 00

16. Long-term care insurance deduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 . 00

17. Health care sharing ministry deduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 . 00

18. Active Duty Military income deduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 . 00

19. Inactive Duty Military income deduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 . 00

20. Bring jobs home deduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 . 00

21. Transportation facilities deduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 . 00

A. Port Cargo Expansion B. International Trade Facility C. Qualified Trade Activities

MO-1040 Page 2
 22. First time home buyers deduction. A. B. 22 . 00

23. Long term dignity savings account deduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 . 00

Deductions Continued

24. Foster parent tax deduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 . 00

25. Total deductions - Add Lines 8 and 13 through 24 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 13119 . 00

26. Subtotal - Subtract Line 25 from Line 6 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 4641 . 00

27. Multiply Line 26 by appropriate percentages (%) on

Lines 7Y and 7S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27Y 4641 . 00 27S . 00

28. Enterprise zone or rural empowerment zone income

modification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28Y . 00 28S . 00

29. Taxable income - Subtract Line 28 from Line 27 . . . . . . . . . . . 29Y 4641 . 00 29S . 00

30. Tax (see tax chart on page 26 of the instructions). . . . . . . . . . 30Y 106 . 00 30S . 00

31. Resident credit - Attach Form MO-CR and other states’

income tax return(s). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31Y . 00 31S . 00

32. Missouri income percentage - Enter 100% unless you are

completing . Attach Form MO-NRI and a
copy of your federal return if less than 100% . . . . . . . . . . . . . 32Y 100 % 32S 100 %
Tax

33. Balance - Subtract Line 31 from Line 30; OR

multiply Line 30 by percentage on Line 32 . . . . . . . . . . . . . . . 33Y 106 . 00 33S . 00

34. Other taxes - Select box and attach federal form indicated.

Lump sum distribution (Form 4972)

Recapture of low income housing credit (Form 8611) 34Y . 00 34S . 00

35. Subtotal - Add Lines 33 and 34 . . . . . . . . . . . . . . . . . . . . . . . . 35Y 106 . 00 35S . 00

36. Total Tax - Add Lines 35Y and 35S. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 106 . 00

37. MISSOURI tax withheld - Attach Forms W-2 and 1099. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 290 . 00

38. 2022 Missouri estimated tax payments - Include overpayment from 2021 applied to 2022 . . . . . . . . 38 . 00
Payments and Credits

39. Missouri tax payments for nonresident partners or S corporation shareholders - Attach Forms
MO-2NR and MO-NRP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 . 00

40. Missouri tax payments for nonresident entertainers - Attach Form MO-2ENT . . . . . . . . . . . . . . . 40 . 00

41. Amount paid with Missouri extension of time to file (Form MO-60). . . . . . . . . . . . . . . . . . . . . . . . 41 . 00

42. Miscellaneous tax credits (from Form MO-TC, Line 13) - Attach Form MO-TC . . . . . . . . . . . . . . 42 . 00

43. Property tax credit - Attach Form MO-PTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 . 00

44. Total payments and credits - Add Lines 37 through 43 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 290 . 00

MO-1040 Page 3
 Skip Lines 45 through 47 if you are not filing an amended return.

45. Amount paid on original return. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 . 00

46. Overpayment as shown (or adjusted) on original return . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 . 00

Indicate Reason for Amending

Enter date of IRS report (MM/DD/YY)
Amended Return

A. Federal audit. . . . . . . . . . . . . . . . . . . . . .
Enter year of loss (YY)

B. Net Operating Loss carryback . . . . . . . .

Enter year of credit (YY)

C. Investment tax credit carryback . . . . . . .

Enter date of federal amended return, if filed. (MM/DD/YY)

D. Correction other than A, B, or C . . . . . . .

47. Amended return total payments and credits - Add Lines 44 and 45; subtract Line 46.
Enter on Line 47. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 . 00

48. If Line 44, or if amended return, Line 47, is larger than Line 36, enter the difference.
Amount of OVERPAYMENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 184 . 00

49. Amount of Line 48 to be applied to your 2023 estimated tax . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 . 00

50. Enter the amount of your donation in the trust fund boxes below. See instructions for additional trust fund codes.

Elderly Home Missouri

Children’s Veterans Delivered Meals National Guard
50a. Trust Fund . 00 50b. Trust Fund . 00 50c. Trust Fund . 00 50d. Trust Fund . 00

Childhood Missouri
Workers’ Lead Military Family General
50e. Memorial Fund . 00 50f. Testing Fund . 00 50g. Relief Fund . 00 50h. Revenue Fund . 00
Soldiers
Kansas City Memorial
Regional Law
Enforcement Military MIssouri
Museum in Medal of
50i.
Organ Donor
. 00 50j. Memorial
. 00 50k. . 00 50l. . 00
Refund

Program Fund Foundation Fund St. Louis Fund Honor Fund

Additional Additional Additional Additional

Fund Fund Fund Fund
50m. Code Amount . 00 50n. Code Amount . 00

Total Donation - Add amounts from Boxes 50a through 50n and enter here . . . . . . . . . . . . . . . . 50 . 00

51. Amount of Line 48 to be deposited into a Missouri 529 Education Plan (MOST)
account. Enter the total deposit amount from Form 5632 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 . 00

52. REFUND - Subtract Lines 49, 50, and 51 from Line 48 and enter here . . . . . . . . . . . . . . . . . . . . 52 184 . 00

a. Routing
Number c. Checking Savings
b. Account
Number

MO-1040 Page 4
 53. If Line 36 is larger than Line 44 or Line 47, enter the difference.
Amount of UNDERPAYMENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 . 00
Amount Due

54. Underpayment of estimated tax penalty - Attach Form MO-2210. Enter penalty amount here . . . 54 . 00

Select this box if you are a farmer exempt from the underpayment of estimated tax penalty.

55. AMOUNT DUE - Add Lines 53 and 54.

If you pay by check, you authorize the Department of Revenue to process the check
electronically. Any returned check may be presented again electronically . . . . . . . . . . . . . . . . . . 55 . 00

Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best
of my knowledge and belief it is true, correct, and complete. By signing or entering my name in the “Signature” field(s) below, I am providing
the Department of Revenue with my signature as required under Section 143.561, RSMo. Declaration of preparer (other than taxpayer) is
based on all information of which he or she has knowledge. As provided in Chapter 143, RSMo., a penalty of up to $500 shall be
imposed on any individual who files a frivolous return. I also declare under penalties of perjury that I employ no illegal or
unauthorized aliens as defined under federal law and that I am not eligible for any tax exemption, credit, or abatement if I employ such
aliens. I am aware of any applicable reporting requirements of Section 135.805, RSMo, and the penalty provisions of Section 135.810,
RSMo.
Signature Date (MM/DD/YY)

Spouse’s Signature (If filing combined, BOTH must sign) Date (MM/DD/YY)

E-mail Address Daytime Telephone

Signature

HXNEYYCXMBS@GMAIL.COM 636 293 4180

Preparer’s Signature Date (MM/DD/YY)

0 3 2 6 2 4
Preparer’s FEIN, SSN, or PTIN Preparer’s Telephone

Preparer’s Address State ZIP Code

I authorize the Director of Revenue or delegate to discuss my return and attachments with the preparer
or any member of the preparer’s firm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes X No

Did you pay a tax return preparer to complete your return, but the preparer failed to sign the return or provide
CP+PVGTPCN4GXGPWG5GTXKEGRTGRCTGTVCZKFGPVKſECVKQPPWODGT!+H[QWOCTMGF[GURNGCUGKPUGTVVJG
preparer’s name, address, and phone number in the applicable sections of the signature block above. . . . . . . Yes X No

Department Use Only

A FA E10 DE F .

Form MO-1040 (Revised 12-2022)

Mail to: Balance Due: Refund or No Amount Due: Fax: (573) 522-1762
Missouri Department of Revenue Missouri Department of Revenue Email: incometaxprocessing@dor.mo.gov
P.O. Box 3370 P.O. Box 3222 Submission of Individual Income Tax Returns
Jefferson City, MO 65105-3370 Jefferson City, MO 65105-3222 Email: income@dor.mo.gov
Phone: (573) 751-7200 Phone: (573) 751-3505 Inquiry and correspondence
Ever served on active duty in the United States Armed Forces?
If yes, visit dor.mo.gov/military/VQUGGVJGUGTXKEGUCPFDGPGſVUYGQHHGTVQCNNGNKIKDNGOKNKVCT[
KPFKXKFWCNU#NKUVQHCNNUVCVGCIGPE[TGUQWTEGUCPFDGPGſVUECPDGHQWPFCV
XGVGTCPDGPGſVUOQIQXUVCVGDGPGſVU/.
MO-1040 Page 5
Visit dor.mo.gov/taxation/individual/tax-types/income/ for additional information.