Declaration under 115.306, RSMo: I hereby declare under penalties of perjury that I am not currently aware
of any delinquency in the ling 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 ofcer of any fee ofce 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 fullling any bonding requirements for the ofce for which I am ling.
Candidate Information
Form
5120
Missouri Department of Revenue
Candidate’s Affidavit of Tax Payments
and Bonding Requirements
First Name Middle Name Last Name
Social Security Number County of Residence Telephone Number*
| | | | | | | |
Street Address* City State Zip Code
Elected Ofce Candidate is Seeking E-mail Address
Signature
Signature Date (MM/DD/YYYY)
___ ___ / ___ ___ / ___ ___ ___ ___
Notary Information
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)
Embosser or black ink rubber stamp seal
__ __ /__ __ /__ __ __ __
Mail to: Missouri Department of Revenue Phone: (573) 751-4450
General Counsel’s Office TTY: (800) 735-2966
P.O. Box 475 Fax: (573) 751-7151
Jefferson City, MO 65105
Visit http://dor.mo.gov/personal/candidates/
for additional information.
Form 5120 (Revised 08-2015)
(___ ___ ___)___ ___ ___-___ ___ ___ ___
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.
* Please update the Department should any information change
