APPLICATION FOR NON-RESIDENT TAX OFFSET CREDIT University of Missouri - St. Louis Cashier's Office (314) 516-5151 285 Millennium Student Center firstname.lastname@example.org One University Blvd. St. Louis, MO 63121-4400 Credit For: SUMMER 2009 FALL 2009 SPRING 2010 Requires Tax Information from the tax year of 2008 Student's Information Last Name First Name Middle Initial Social Security Number Student Number Taxpayer's Information Last Name First Name Middle Initial Social Security Number Email Address (Optional) Mailing Address City State Zip Daytime Phone Number REQUIRED DOCUMENTATION 1. Missouri State income tax returns (MO-1040) for the tax year indicated at the top of the application, including the Non- Resident Schedule. If the student is not the taxpayer listed on the MO-1040, then the front page of your 1040 Federal Income Tax form that lists the student by name or Social Security Number can be used in conjunction with your MO-1040 to prove status as a dependent. 2. All W2's, 1099's, or Schedules that indicate the source of the Missouri income for the tax year noted at the top of the application. 3. A copy (front and back) of the canceled check to Missouri Department of Revenue for Missouri State Tax payments made. If paid by credit card, please provide a copy of your credit card statement detailing payments made. (if applicable) 4. Copies of the above documentation will need to be submitted with the application. This information will not be returned. It is the students responsibility to obtain copies of the appropriate documentation. (This Cashier's office does not provide copy service.) TERMS AND CONDITIONS 1. The student must be listed by name as a dependent of the tax payer. 2. The credit applied is based on taxes that were due and paid, not taxes withheld. 3. Only taxes paid during the specified year can be applied towards the semesters indicated. A credit will be placed on your account for subsequent semesters until either the tax credit has been depleted or the semester no longer qualifies. The tax credit can not be carried forward beyond the semesters specified on this form. 4. The taxpayer must have accrued a personal income tax liability in the year for which the tax off set credit originates. 5. The tax credit can only offset against the Non-Resident Educational Fee. The total of the credit for the semesters can not be greater than the Missouri State Taxes paid in the tax year specified. 6. This application must be completed and approved at least one week prior to a fee payment deadline. If you fail to do so you will be required to pay the full Non-Resident Educational Fee and will be reimbursed, if your application is approved. 7. This application must be signed by both the Student and the Taxpayer. By signing this form you acknowledge and agree that the information on and submitted with this application can be discussed with either party. If a joint return is filed, both tax payer signatures are required. All information requirements and conditions of this credit are subject to change without notice. The Cashier's Office may need to request additional information before a credit is issued. The application must be approved by the Cashier's Office and should not be considered a contract. Signature of Student Date Signature of Tax Payer Date Signature of Joint Filer Date
"Application for Tax credit"