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                                                                           Form
                                                                                      Missouri Department of Revenue
                                                5310                                  Application for Voluntary Disclosure Agreement

The Missouri Department of Revenue welcomes individuals, partnerships, corporations, etc. who wish to voluntarily disclose any unpaid 
taxes administered by the Department. Entities may approach the Department anonymously, through a representative, or otherwise. 
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.
Please answer ALL questions. Applications that are not entirely completed cannot be processed.
                                                                           Name                                                             Company

                                                                           Title                                                            Address                                                                  

                                                                           City                                               State          Zip Code                  Telephone Number                     
                                                                                                                                                          ( ___ ___ ___ ) - ___ ___ ___ - ___ ___ ___ ___
                        Individual, Entity, or                             Fax Number                                      E-mail Address
                                                Representative Information ( ___ ___ ___ ) - ___ ___ ___ - ___ ___ ___ ___

1. Applicant is a(n) (select one)

                                                r C Corporation                       r Limited Liability Company taxed as a Corporation            r Limited Liability Partnership 
                                                r Fiduciary                           r Limited Liability Company taxed as a Disregarded Entity     r Limited Partnership 
                                                r Individual                          r Limited Liability Company taxed as a Partnership            r Partnership
                                                                                                                                                    r S Corporation

2. Is the applicant domiciled in Missouri? r  Yes   r  No

3. Which type(s) of tax is the applicant currently registered for and filing in Missouri?
 
                                                r                          Consumer’s Use     r  Individual               r   Vendor’s Use r   Not Registered r   Insurance Premium Tax
                                                r                          Corporation Income r  Fiduciary                r   Sales        r   Withholding

4. Which type(s) of tax does the applicant need to disclose?

                                                r                          Consumer’s Use     r  Individual               r   Vendor’s Use 
                                                r                          Corporation Income r  Fiduciary                r   Sales        r   Withholding

5. If the type of business has changed during the last five years, indicate the type(s) of the predecessor entities and the periods in which they existed.

6. What is the applicant’s fiscal year-end?

7. If the fiscal year-end has changed within the past five years, please list all fiscal year-ends. 

8. What date did the applicant begin conducting business in Missouri? Please indicate month and year.

                                                                                                                                                                                           Form 5310 (Revised 09-2021)
                                                                                                   *14310010001*
                                                                                                                               14310010001

9. What are the applicant’s business activities? Example: “A manufacturer of tangible personal property that sells primarily to contractors who  
  incorporate the material into buildings and landscape designs.”

10. If the applicant makes sales from outside the state to in-state customers, may a customer return the applicant’s product for refund, exchange,  
    repair, or other value?        r Yes   r No   r N/A       If yes, please briefly describe how this is done.

11. Is  the applicant an owner, lessor, or lessee of property in Missouri?  Please describe and include  both real property, personal  
    property, and intellectual property, e.g., trademarks or patents.

12.  Has  the applicant  had  personnel in  Missouri  for  any  period of time,  whether  employees,  independent  contractors,  affiliates,  or  other 
 representatives? Include all contacts, even if transitory. Generally describe their activities, their approximate amount of time spent in the  
 state, and their relationship to the applicant, if not previously described. 

13. What other activities does the applicant engage in that potentially give rise to nexus? 

14. 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. 

15. Has the applicant contacted or been contacted by Missouri or the Multistate Tax Commission concerning unpaid taxes? 
 r Yes  r No       If yes, please explain.

16. What years does the oversight encompass?

17. What taxes have been collected but not remitted?
  r   Sales Tax     r   Vendor’s Use Tax     r      None     r   N/A

                                                                                                               Form 5310 (Revised 09-2021)
                                             *14310010001*
                                                    14310010001

18. What is the overall estimated tax liability for periods covered under the Voluntary Disclosure Agreement (VDA)?

19. Please provide any information not already provided that you believe the Department should have with respect to this application. 

20. How did you learn about the Voluntary Disclosure Program?
 
 r Business or personal reference             r Previous Disclosure  
 r CPA or attorney                            r State of Missouri website
 r Missouri Department of Revenue website     r Other (Please specify) ____________________________________________

                                  *14310020001*
                                                     14310020001
                                                                                                                      Form 5310 (Revised 09-2021)
Mail to:   Taxation Division           E-mail:  nexus@dor.mo.gov
          P.O. Box 295                 Visit dor.mo.gov/taxation/business/voluntary-disclosure-program/ for additional information.
          Jefferson City, MO 65105-0295
         
 Phone:  (573) 522-4989                Ever served on active duty in the United States Armed Forces?  
                                       If yes, visit dor.mo.gov/military/ to see the services and benefits we offer to all eligible military 
 Fax:    (573) 522-1762                individuals. A list of all state agency resources and benefits can be found at 
                                       veteranbenefits.mo.gov/state-benefits/.