Form 5439 - Authorization And Release For New Officers

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MISSOURI DEPARTMENT OF REVENUE

FORM

LICENSE OFFICES BUREAU

5439

AUTHORIZATION & RELEASE FOR NEW OFFICERS

(REV. 08-2012)

LICENSE OFFICE

AGENT/MANAGER

PHONE NUMBER

New Officers of the License Office must complete this form. The processing fee for the background check is $10.00

and will be debited from the License Office Agent’s monthly long and short account.

FULL NAME

TITLE

SOCIAL SECURITY NUMBER

HOME PHONE NUMBER

DATE OF BIRTH

CELL PHONE NUMBER

EMAIL ADDRESS

MAILING ADDRESS

FAX NUMBER

CITY, STATE, ZIP CODE

SPOUSE’S MAILING ADDRESS

SPOUSE’S FULL NAME, if married and filing joint returns

SPOUSE’S SOCIAL SECURITY NUMBER

CITY, STATE, ZIP CODE

SPOUSE’S DATE OF BIRTH

SPOUSE’S CELL PHONE NUMBER

LIST ALL MOTOR VEHICLES, TRAILERS, ALL-TERRAIN VEHICLES, VESSELS, AND OUTBOARD MOTORS OWNED OR CO-OWNED BY

THE PERSON THAT ARE REQUIRED TO BE TITLED IN MISSOURI. ALSO LIST ALL LEASED VEHICLES, IF RESPONSIBLE FOR THE

(Attach additional sheets if necessary):

REGISTRATION AND PAYMENT OF PERSONAL PROPERTY TAXES ON THE UNITS

VEHICLE ID # OR MISSOURI TITLE #

YEAR

MAKE/MODEL

1. ARE YOU, OR A FAMILY MEMBER, AN ELECTED OR APPOINTED OFFICIAL OF THE STATE OF MISSOURI OR ANY

POLITICAL SUBDIVISION (OR EMPLOYED BY THEM)?

YES

2. ARE YOU A BUSINESS ENTITY WITH WHICH AN ELECTED OR APPOINTED OFFICIAL OR A FAMILY MEMBER OF AN ELECTED OR

APPOINTED OFFICIAL IS ASSOCIATED?

YES

IF YOU MARKED “YES” TO 1 OR 2 ABOVE, COMPLETE FORM 5405 AND SUBMIT WITH THIS FORM.

DO YOU OWN A BUSINESS OR ARE YOU AN OFFICER OF A BUSINESS FOR WHICH YOU ARE RESPONSIBLE FOR THE PAYMENT OF

If Yes, complete the business information below (Attach additional sheets if necessary):

MISSOURI SALES OR INCOME TAX:

YES

DOING BUSINESS AS (DBA) NAME

LEGAL NAME OF BUSINESS FILED WITH IRS FOR THE TAX ID # LISTED BELOW

IRS FORM 1099 MAILING ADDRESS

CITY, STATE, ZIP CODE

CONTACT PERSON

PHONE NUMBER

FAX NUMBER

EMAIL ADDRESS

MO TAX ID # or EXEMPTION #

FEIN

CHARTER # / CERTIFICATE OF AUTHORITY #

By my signature below, I hereby authorize the Missouri Department of Revenue (DOR) to check for compliance for at least the last five years of the: (1) Federal and

Missouri tax records including, but not limited to, individual income tax, corporate tax, state sales and use tax, withholding tax, and employment security tax pertaining

to me and to any corporations, partnerships or companies for which I am responsible; (2) the title and registration records on all vehicles, trailers, ATVs, vessels, and

outboard motors (units) that I and any business for which I am responsible owns or co-owns for proper registration and any outstanding sales and use tax delinquencies;

and (3) property tax payment records on the above units. I do hereby release the State of Missouri, Department of Revenue (DOR), and other persons, firms, corporations,

and institutions from any and all liability or responsibility in the conduct of any such check or investigation and the disclosure of any information relating thereto. The

authorization reflected above shall remain in full force and effect until such time as actual notice of termination of such authorization is delivered in writing to the DOR.

A copy of this authorized Exhibit shall have the same effect as the original. I further authorize the Missouri State Highway Patrol to furnish the DOR with any and all

information requested about my criminal history or background, including any record of conviction, plea of guilty or nolo contendere or finding of guilt for a felony or

misdemeanor. I authorize the DOR to disclose any of the above findings to the Agent/Manager of the license office listed above. I understand the DOR may conduct and/

or review a background investigation before rendering a decision regarding my eligibility to perform services and agree to cooperate in such investigation.

AUTHORIZED SIGNATURE

DATE

PRINTED NAME

TITLE

DOR OFFICE USE ONLY

OFFICE USE ONLY

The motor vehicle title and registration records and the personal property tax

The Department of Revenue tax compliance review has been conducted.

records for the vehicles listed above have been verified.

DATE

SIGNATURE

DATE