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Form 5120 - Candidate'S Affidavit Of Tax Payments

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MISSOURI DEPARTMENT OF REVENUE

FORM

GENERAL COUNSEL’S OFFICE

301 WEST HIGH STREET, PO BOX 475

5120

JEFFERSON CITY, MO 65105

CANDIDATE’S AFFIDAVIT OF TAX PAYMENTS

(REV 11-2007)

I hereby declare under penalty of perjury, pursuant to Section 115.342, RSMo, that I am not delinquent in the

filing or payment of any state income taxes, personal property taxes, real property taxes on my place of

residence, as stated on my declaration of candidacy, and that I am not a past or present corporate officer of

any fee office that owes any taxes to the state, other than those taxes which may be in dispute.

CANDIDATE’S SIGNATURE

COUNTY OF RESIDENCE

PRINTED NAME OF CANDIDATE (LAST, FIRST, MIDDLE)

CANDIDATE’S AREA CODE AND TELEPHONE NUMBER

CANDIDATE’S SOCIAL SECURITY NUMBER

ELECTED OFFICE CANDIDATE IS SEEKING

CANDIDATE’S RESIDENCE STREET ADDRESS

CITY, STATE, AND ZIP CODE

State of Missouri, County (and/or City) of ___________________________________________________

City and/or County

on this ______________________ day of _________________________________, 20_____, before me,

_____________________________________________________________________________________,

Notary's Name

a Notary Public in and for said state, personally appeared ______________________________________.

Candidate's Name

known to me to be the person who executed the within Affidavit and acknowledged to me that he or she

executed same for the purposes therein stated.

SEAL

My Commission Expires:___________________________________

Upon request by the Department of Revenue, the candidate shall provide a copy of paid tax receipts

for the candidate’s personal property taxes and real property taxes and any other information

necessary to demonstrate compliance with Section 115.342, RSMo.

Send Affidavit to: General Counsel’s Office

Missouri Department of Revenue

P.O. Box 475

301 West High Street

Jefferson City, MO 65105

Form 5120 - Candidate'S Affidavit Of Tax Payments

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