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                                                                                                             Department Use Only
                                                 Form      Missouri Department of Revenue                    (MM/DD/YY)
                                                           Offer in Compromise Waiver
                                                 5237

Missouri Tax I.D.                                                                                 Federal Employer
Number                                                                                            I.D. Number

Social Security
Number

                                                 Name                                                                  Phone Number

                                                                                                                       (___ ___ ___) ___ ___ ___-___ ___ ___ ___
                                                 Address

                                                 City                                                                  State             ZIP Code
                    Taxpayer Information

                                                 In connection with the above-named individual’s, company’s, or organization’s offer in  compromise request to 
                                                 the Missouri Department of Revenue, relating to the Missouri Department of Economic Development’s (DED) 
                                                 Tax Credit Penalties imposed under Section 135.810, RSMo, I am signing this waiver to permit the Department 
                                                 to release otherwise confidential tax information about the individual, company, or organization to appropriate  
                                                 officials of DED. This waiver is limited to all information pertaining to any tax period within the current and past 
                                                 three calendar years, and any information pertaining to the offer in compromise.
                                                 I am authorized to sign this document as the individual or as an officer, partner, or owner of the company or  
                                                 organization. This authorization shall be effective from this date and shall expire upon final determination as to 
                                                 the offer in compromise submitted contemporaneously with this waiver. 
                                                 The Director of Revenue and the Department’s personnel are hereby released from any and all  liability under 
                                                 Section 32.057, RSMo, or any other applicable confidentiality statute, related to the unauthorized disclosures of 
                                        Signature
                                                 confidential tax information resulting from the release of information to DED.
                                                 Under penalty of perjury, I declare that I have examined this authorization and, to the best of my knowledge and 
                                                 belief it is true, correct, and complete. If prepared by a person other than the individual or owner, this declaration 
                                                 is based on all information of which the undersigned has any knowledge.

                                                 Signature                                                             Title

                                                 Printed Name                                                          Date (MM/DD/YYYY)

                                                                                                                       ___ ___ /___ ___ /___ ___ ___ ___
                                                                                                                                                Form 5237 (Revised 12-2014)

Mail to:  Taxation Division 
                                                      P.O. Box 27 
                                                      Jefferson City, MO 65105-0027
                                                 Corporate Tax                     Personal Tax
                                                 Phone: (573) 751-4541             Phone: (573) 751-3220
                                                 Fax: (573) 522-8619               Fax: (573) 522-8619                         Visit dor.mo.gov 
                                                 E-mail:  taxcredit@dor.mo.gov     E-mail:  taxcredit@dor.mo.gov        for additional information.

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