Fillable Printable Form 5674 Verification Of Rent Paid

Form 5674 Verification Of Rent Paid

*16325010001*

16325010001

Tenant and Rental Information

Missouri Department of Revenue

Verification Of Rent Paid

Department Use Only

(MM/DD/YY)

Tenant’s Name

Form

5674

Landlord Information

Section 143.941, RSMo. states in part: (...upon conviction thereof, be ned not more than ten thousand dollars, or be imprisoned

in the county jail for not more than one year or by not less than two nor more than ve years in the state penitentiary or by both

ne and imprisonment together with the cost of prosecution.)

Notice

Landlord must complete this form each year.

Form 5674 (Revised 08-2016)

Taxation Division Phone: (573) 751-3505

P.O. Box 2200 TTY: (800) 735-2966

Jefferson City, MO 65105-2200 Fax: (573) 751-2195

Visit http://dor.mo.gov

for additional information.

Rental Begin Date (MM/DD/YY) Rental End Date (MM/DD/YY)

Gross Rent Paid for the Year .............................................................

Amount of utilities included in monthly payment (if any).........................................

Rental Address

Landlord’s Name

Telephone Number (Cell)Telephone Number (Home)

Landlord’s SignatureTelephone Number (Work)

Did the tenant receive any housing assistance? ........................................................... Yes No

If yes, how much rent was the tenant responsible for? ......................................

Did anyone reside at this dwelling with the above tenant?.................................................... Yes No

If yes, how many were over the age of 18? ...............................................

Any Person intentionally ling a fraudulent Property Tax credit Claim may be prosecuted.

Tax Year

City

State

ZIP Code

Landlord’s Address

City

State

ZIP Code

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