5310 Application For Voluntary Disclosure Agreement Page 2
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210. What are the facts giving rise to the request for a voluntary disclosure agreement? include any facts relative to whether the failure to
register, file or remit was due to reasonable cause and not due to negligence, intentional disregard of the law, or fraud.
11. Has the applicant contacted or been contacted by missouri or the multistate tax commission concerning unpaid taxes?
o yes
if yes, please explain.
o no
12. Which type(s) of tax is the applicant currently registered for and filing in missouri?
o sales o vendor’s use
o consumer’s use
o corporation income
o corporation franchise
o Withholding
o fiduciary
13. Which type(s) of tax does the applicant need to disclose?
o sales o vendor’s use
o consumer’s use
o corporation income
o corporation franchise
o Withholding
o fiduciary
o individual
14. What years does the oversight encompass, and if a business, what taxes have been collected but not remitted?
15. please provide any information not already provided that you believe the department should have with respect to this application.
16. How did you learn about the voluntary disclosure program?
o previous disclosure
o missouri department of revenue web site
o state of missouri web site
o cpa or attorney
o business or personal reference
o other(please specify) _____________________________________________________
_________________________________________________________________________________________________
the name of the individual or entity does not need to be revealed until the agreement is finalized. a representative should be used to
remain anonymous. upon receipt of the completed application, the department will review the facts presented and, if appropriate, offer
an agreement to the individual or representative for review and approval.
individual, entity, or representative information:
name:_____________________________________________________________________________________
title:______________________________________________________________________________________
company:__________________________________________________________________________________
address:___________________________________________________________________________________
telephone number:__________________________________________________________________________
e-mail:____________________________________________________________________________________
fax:______________________________________________________________________________________
mail to:
missouri department of revenue
post office box 295
jefferson city, mo 65105-0295
e-mail: nexus@dor.mo.gov
click to submit via e-mail
fax: (573) 522-1721
dor-5310 (03-2011)
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