Form 5378 - Agreement To Receive Refund By Ach Transfer
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FORM
MISSOURI DEPARTMENT OF REVENUE
5378
TAXATION DIVISION
AGREEMENT TO RECEIVE REFUND BY ACH TRANSFER
(REV. 09-2012)
Please complete this form and return using one of the methods listed below. Check one box for the appropriate tax type.
SALES AND USE TAX
MOTOR FUEL TAX
CIGARETTE TAX/OTHER
FINANCIAL INSTITUTIONS/
Taxation Division
Taxation Division
TOBACCO PRODUCTS TAX
INSURANCE TAXES
P.O. Box 3350
P.O. Box 300
Taxation Division
Taxation Division
Jefferson City, MO 65105-3350
Jefferson City, MO 65105-0300
P.O. Box 811
P.O. Box 898
Telephone: (573) 526-9938
Telephone: (573) 751-2611
Jefferson City, MO 65105-0811
Jefferson City, MO 65105-0898
Fax: (573) 751-9409
Fax: (573) 522-1720
Telephone: (573) 751-7163
Telephone: (573) 751-2326
E-mail:
salesrefund@dor.mo.gov
E-mail:
excise@dor.mo.gov
Fax: (573) 522-1720
Fax: (573) 522-6816
E-mail:
excise@dor.mo.gov
E-mail:
fit@dor.mo.gov
WITHHOLDING TAX
CORPORATE TAX
Taxation Division
Taxation Division
P.O. Box 3375
P.O. Box 3365
Jefferson City, MO 65105-3375
Jefferson City, MO 65105-3365
Telephone: (573) 751-8750
Telephone: (573) 751-4541
Fax: (573) 522-6816
Fax: (573) 522-1721
E-mail:
withholding@dor.mo.gov
E-mail:
corporate@dor.mo.gov
TYPE OF AGREEMENT (CHECK ONE):
NEW
CHANGE
CANCEL
COMPANY NAME
COMPANY ADDRESS
We acknowledge that the Department reserves the right to provide distribution by check or other means as it deems
necessary. The undersigned designate the following as the account to which the Department should credit ACH of the refund:
1.
RECEIVING BANK NAME
RECEIVING BANK ADDRESS
2.
RECEIVING BANK ROUTING NUMBER (ABA)
3.
COMPANY ACCOUNT NAME (AT THE BANK)
4. COMPANY BANK ACCOUNT NUMBER (AT THE BANK)
CHECKING
SAVINGS
INCLUDE A VOIDED DEPOSIT TICKET, VOIDED CHECK OR LETTER FROM THE BANKING INSTITUTION
AS VERIFICATION OF THE ABOVE INFORMATION.
Two (2) company official authorized signatures are required.
Under penalties of perjury, we, as authorized representatives of the company for the tax described above, declare that the above
information is, to the best of our knowledge and belief, true, correct and complete.
COMPANY OFFICIAL SIGNATURE
TITLE
COMPANY OFFICIAL SIGNATURE
TITLE
COMPANY OFFICIAL NAME (TYPE OR PRINT)
COMPANY OFFICIAL NAME (TYPE OR PRINT)
TELEPHONE NUMBER
FAX NUMBER
E-MAIL ADDRESS
DO NOT WRITE IN THIS AREA. DEPARTMENT OF REVENUE USE ONLY.
SIGNATURE
TITLE
DATE
DOR-5378 (09-2012)
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