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 ofcer of any fee ofce 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 fullling any bonding requirements for the ofce for which I am ling.
Candidate Information
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 Ofce Candidate is Seeking E-mail Address
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
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
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