Form 5094 - Statement Of Facts And Incident
Download a blank fillable Form 5094 - Statement Of Facts And Incident in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form 5094 - Statement Of Facts And Incident with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1Reset Form
Print Form
Missouri Department of Revenue
Form
5094
Statement of Facts and Incident
Please print or type when completing this form.
Comes Now, _____________________________, agent or employee with the Department of Revenue’s _____________________,
Contract Office and hereby states he or she believes the applicant or person provided false or fraudulent information or
documentation, or concealed a material fact, or otherwise committed a fraud in such application on ____________________________,
r
r
at __________
A.M. or
P.M., in violation of Sections
302.177
and
302.233
RSMo, for the following reason(s):
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
_
Please provide information regarding the individual who has attempted fraud (if available).
Name
Driver License or Social Security Number
Date of Birth (MM/DD/YYYY)
___ ___ / ___ ___ / ___ ___ ___ ___
Information or Documentation Presented as Proof of Identity
r
Image Portfolio or copy of Missouri Driver License, Nondriver License, or Permit, if applicable.
(The individual in this photograph has been identified as the person who presented the fraudulent or false documents.
r
r
Yes
No
Is the customer’s address shown on the proof of identity document?
r
r
If yes, is the address shown on the document still correct?
Yes
No
If no, what is the customer’s current address? _______________________________________________________________
r
I was unable to obtain the customer’s address.
Under penalties of perjury, I declare that the above information and any attached supplement is true, complete, and correct.
Agent or Employee’s Signature
Title
Agent or Employee’s Printed Name
Date (MM/DD/YYYY)
__ __ /__ __ /__ __ __ __
Form 5094 (Revised 08-2013)
Mail to:
Driver License Bureau
Phone: (800) 347-6497
Visit
for
Document Verification Unit
Fax: (573) 751-2722
additional information.
P.O. Box 200
E-mail:
dlbmail@dor.mo.gov
Jefferson City, MO 65105-0200
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Financial