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O. Box 2200 Jefferson City MO 65105-2200 Form 5674 Revised 08-2016 Phone 573 751-3505 TTY 800 735-2966 Fax 573 751-2195 E-mail propertytaxcredit dor. Reset Form Form Print Form Department Use Only MM/DD/YY Missouri Department of Revenue Verification Of Rent Paid 16325010001 Landlord must complete this form each year. Tax Year Tenant s Name Tenant and Rental Information Rental Address ZIP Code State City 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. Did the tenant receive any housing assistance. Yes If yes how much rent was the tenant responsible for. Did anyone reside at this dwelling with the above tenant. No If yes how many were over the age of 18. Landlord Information Landlord s Name Landlord s Address Telephone Number Home Landlord s Signature Notice Any Person intentionally filing a fraudulent Property Tax credit Claim may be prosecuted* Section 143. 941 RSMo. states in part. upon conviction thereof be fined 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 five years in the state penitentiary or by both fine and imprisonment together with the cost of prosecution* Taxation Division P. Reset Form Form Print Form Department Use Only MM/DD/YY Missouri Department of Revenue Verification Of Rent Paid 16325010001 Landlord must complete this form each year. Tax Year Tenant s Name Tenant and Rental Information Rental Address ZIP Code State City Rental Begin Date MM/DD/YY Rental End Date MM/DD/YY Gross Rent Paid for the Year. Tax Year Tenant s Name Tenant and Rental Information Rental Address ZIP Code State City 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. Did the tenant receive any housing assistance. Amount of utilities included in monthly payment if any. Did the tenant receive any housing assistance. Yes If yes how much rent was the tenant responsible for. Did anyone reside at this dwelling with the above tenant. Yes If yes how much rent was the tenant responsible for. Did anyone reside at this dwelling with the above tenant. No If yes how many were over the age of 18. Landlord Information Landlord s Name Landlord s Address Telephone Number Home Landlord s Signature Notice Any Person intentionally filing a fraudulent Property Tax credit Claim may be prosecuted* Section 143. No If yes how many were over the age of 18. Landlord Information Landlord s Name Landlord s Address Telephone Number Home Landlord s Signature Notice Any Person intentionally filing a fraudulent Property Tax credit Claim may be prosecuted* Section 143. 941 RSMo. states in part. upon conviction thereof be fined 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 five years in the state penitentiary or by both fine and imprisonment together with the cost of prosecution* Taxation Division P.

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Keywords relevant to Form 5674

  • Taxation
  • fraudulent
  • gov
  • Landlords
  • dor
  • utilities
  • fined
  • verification
  • thereof
  • reside
  • Revised
  • dwelling
  • prosecuted
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