Form 5237 - Offer In Compromise Waiver - Missouri Department Of Revenue

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MISSOURI DEPARTMENT OF REVENUE
FORM
TAXATION DIVISION
5237
P.O. BOX 27, JEFFERSON CITY, MO 65105
OFFER IN COMPROMISE WAIVER
(REV. 06-2009)
Name of Taxpayer ______________________________________________________________________________
Tax Identification Number ________________________________________________________________________
Address ______________________________________________________________________________________
Phone Number ________________________________________________________________________________
In connection with the above-named individual’s, company’s, or organization’s offer in
compromise request to the Missouri Department of Revenue (DOR), relating to
the Missouri Department of Economic Development’s (DED) Tax Credit Penalties
imposed under Section 135.810, RSMo, I am signing this waiver to permit DOR to
release otherwise confidential tax information about the individual, company, or
organization to appropriate officials of DED. This waiver is limited to all information
pertaining to any tax period within the current and past three calendar years, and
any information pertaining to the offer in compromise.
I am authorized to sign this document as the individual or as an officer, partner,
or owner of the company or organization. This authorization shall be effective from
this date and shall expire upon final determination as to the offer in compromise
submitted contemporaneously with this waiver.
The Director of Revenue and DOR personnel are hereby released from any and all
liability under Section 32.057, RSMo, or any other applicable confidentiality statute, related
to the unauthorized disclosures of confidential tax information resulting from the release of
information to DED.
UNDER PENALTY OF PERJURY, I DECLARE THAT I HAVE EXAMINED THIS
AUTHORIZATION AND, TO THE BEST OF MY KNOWLEDGE AND BELIEF, IT
IS TRUE, CORRECT, AND COMPLETE. IF PREPARED BY A PERSON OTHER
THAN THE INDIVIDUAL OR OWNER, THIS DECLARATION IS BASED ON ALL
INFORMATION OF WHICH THE UNDERSIGNED HAS ANY KNOWLEDGE.
Signature ____________________________________________________________________________________
Title ________________________________________________________________________________________
Date ________________________________________________________________________________________
DOR-5237 (06-2009)

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