Form 5120 - Candidate'S Affidavit Of Tax Payments And Bonding Requirements

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Missouri Department of Revenue
Form
Candidate’s Affidavit of Tax Payments
and Bonding Requirements
5120
First Name
Middle Name
Last Name
Social Security Number
County of Residence
Telephone Number*
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Street Address*
City
State
Zip Code
Elected Office Candidate is Seeking
E-mail Address
* Please update the Department should any information change
Declaration under
115.306,
RSMo: I hereby declare under penalties of perjury that I am not currently aware
of any delinquency in the filing or payment of any state income taxes, personal property taxes, municipal
taxes, real property taxes on the place of residence, as stated on my declaration of candidacy, or 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. I declare under penalties of perjury that I am not aware of any information that would
prohibit me from fulfilling any bonding requirements for the office for which I am filing.
Signature
Date (MM/DD/YYYY)
___ ___ / ___ ___ / ___ ___ ___ ___
Embosser or black ink rubber stamp seal
Subscribed and sworn before me, this
day of
year
State
County (or City of St. Louis)
My Commission Expires (MM/DD/YYYY)
__ __ /__ __ /__ __ __ __
Notary Public Signature
Notary Public Name (Typed or Printed)
Please review 115.306, RSMo. A failure to comply may disqualify you from the ballot. Upon request by
the Department of Revenue, the candidate shall provide a copy of tax receipts for the candidate’s personal
property, municipal, and real property taxes, and any other information necessary to demonstrate compliance
with 115.306, RSMo.
Form 5120 (Revised 08-2015)
Phone: (573) 751-4450
Mail to:
Missouri Department of Revenue
TTY: (800) 735-2966
Visit
General Counsel’s Office
P.O. Box 475
Fax: (573) 751-7151
for additional information.
Jefferson City, MO 65105

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