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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) 522-1721              Fax: (573) 522-1721                  Visit http://www.dor.mo.gov/ 
                                                  E-mail:  taxcredit@dor.mo.gov    E-mail:  taxcredit@dor.mo.gov         for additional information.

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