MISSOURI DEPARTMENT OF REVENUE
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FORM
GENERAL COUNSEL’S OFFICE
5121
301 WEST HIGH STREET, PO BOX 475
JEFFERSON CITY, MO 65105
(REV 11-2007)
COMPLAINT PURSUANT TO SECTION 115.342, RSMo
I have probable cause to believe that _______________________________________________________,
Candidate's Name (Last, First, Middle)
_____________________________________________________________________________________
Street Address, City, County, State and Zip Code
a candidate for _________________________________________________________________________
Elected Office
has failed to file and pay the following taxes that are due and owing and to my knowledge are not in dispute.
Check all that apply.
State Income Taxes
Personal Property Taxes
Real Property Taxes on his/her Place of Residence
Candidate is or was a corporate officer of a fee office that owes taxes to the state.
The facts upon which I have probable cause to believe a tax or taxes are owed are as follows:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
COMPLAINANT’S SIGNATURE
PRINTED NAME OF COMPLAINANT (LAST, FIRST, MIDDLE)
COMPLAINANT’S RESIDENCE STREET ADDRESS
DAYTIME TELEPHONE (INCLUDING AREA CODE)
CITY, COUNTY, 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 ______________________________________.
Complainant’s Name
known to me to be the person who executed the within Complaint and acknowledged to me that he or she
executed same for the purposes therein stated.
SEAL
My Commission Expires:___________________________________
Send Complaint and any attachments to:
General Counsel’s Office
Missouri Department of Revenue
P.O. Box 475
301 West High Street
Jefferson City, MO 65105