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

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