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   Form 
                    Agreement to Receive Refund by ACH Transfer
 5378

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

Primary Taxpayer                                                  Secondary Taxpayer
Social Security                                                   Social Security
Number                                                            Number

Please complete this form and return using one of the methods listed below. Select one box for the appropriate tax type.

 r Sales and Use Tax              r Motor Fuel Tax                 r  Cigarette Tax and Other    r Financial Institutions and 
   Taxation Division                Taxation Division                 Tobacco Products Tax            Insurance Taxes
   P.O. Box 3350                    P.O. Box 300                      Taxation Division               Taxation Division
   Jefferson City, MO 65105-3350    Jefferson City, MO 65105-0300     P.O. Box 811                    P.O. Box 898
   Phone: (573) 526-9938            Phone: (573) 751-2611             Jefferson City, MO 65105-0811   Jefferson City, MO 65105-0898
   Fax: (573) 751-9409              Fax: (573) 522-1720               Phone: (573) 751-7163           Phone: (573) 751-2326   
   E-mail: salesrefund@dor.mo.gov   E-mail: excise@dor.mo.gov         Fax: (573) 522-1720             Fax: (573) 522-1721
                                                                      E-mail: excise@dor.mo.gov       E-mail: fit@dor.mo.gov
 r Withholding Tax              r  Corporate Tax          r      Business Tax Registration Bond      r Individual or Partnership Tax
   Taxation Division               Taxation Division             Taxation Division                      Taxation Division
   P.O. Box 3375                   P.O. Box 3365                 P.O. Box 357                           P.O. Box 2200
   Jefferson City, MO 65105-3375   Jefferson City, MO 65105-3365 Jefferson City, MO 65105-0357          Jefferson City, MO 65105-2200
   Phone: (573) 751-8750           Phone: (573) 751-4541         Phone: (573) 751-5860                  Phone: (573) 751-3505   
   Fax: (573) 522-6816             Fax: (573) 522-1721           Fax: (573) 522-1722                    Fax: (573) 522-1762
   E-mail: withholding@dor.mo.gov  E-mail: corporate@dor.mo.gov  E-mail: businesstaxregister@dor.mo.gov E-mail: income@dor.mo.gov

 r Pass-Through Entity Tax      r  Fiduciary Tax
   Taxation Division               Taxation Division
   P.O. Box 3080                   P.O. Box 3815
   Jefferson City, MO 65105-3080   Jefferson City, MO 65105-3815
   Phone: (573) 751-5860           Phone: (573)751-1467
   Fax: (573) 522-1721             Fax: (573) 522-1762
   E-mail: corporate@dor.mo.gov    Email: dor.fiduciary@dor.mo.gov

                                             Company or Individual (Payee) Information

 Type of Agreement (Select One)                       Tax Period 
        r New     r Change      r Cancel
 Name

 Address                                             City                                       State                   ZIP Code

                                             *14501010001*
                                                                 14501010001

                                              Financial Institution (Banking) Information
We acknowledge that the Department of Revenue reserves the right to refund by check or other means as it deems necessary. The 
undersigned designate the following as the account to which the Department should credit ACH the refund. See instructions on Page 3.
1. Financial Institution Name

Address                                        City                                      State                              ZIP Code

2. Company Account Name

3. ABA Routing Number                          4. Account Number
                                                                                         r Checking    r Savings
          Include a voided check or letter from the financial institution as verification of the above information.

                                                               Signature
Two (2) company official authorized signatures are required or the primary and secondary taxpayer, if applicable. If your banking information 
changes following the submission of this form, you must submit an updated Form 5378 to ensure your payment is deposited in the 
appropriate account.
Under penalties of perjury, I declare that the above information and any attached supplement is true, complete, and correct.

Company Official/Primary Taxpayer Signature                    Company Official/Primary Taypayer Printed Name  

Title                                         E-mail Address

Telephone Number                              Fax Number                                  Date Signed (MM/DD/YYYY)
(__ __ __) __ __ __ - __ __ __ __             (__ __ __) __ __ __ - __ __ __ __           __ __ /__ __ /__ __ __ __

Company Official/Secondary Taxpayer Signature                  Company Official/Secondary Taxpayer Printed Name

Title                                         E-mail Address

Telephone Number                              Fax Number                                  Date Signed (MM/DD/YYYY)
(__ __ __) __ __ __ - __ __ __ __             (__ __ __) __ __ __ - __ __ __ __           __ __ /__ __ /__ __ __ __

                                               Department Use Only
Signature                                      Title                                                                      Date (MM/DD/YYYY)
                                                                                                                          __ __ /__ __ /__ __ __ __

                                              *14501020001*
                                                               14501020001

                             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 individuals. A list of all state agency resources and benefits can be found at 
                             veteranbenefits.mo.gov/state-benefits/.

                     ACH Transfer Agreement Instructions

To provide more security, the Department of Revenue will send large dollar refunds via ACH (Automated Clearing 
House) transfer.
Financial Institution (Banking) Information
 1.  Financial Institution Name and Address:  Enter your financial institution’s name and address.
 2.  Account Name: Enter your account name at the financial institution.
 3.  ABA Routing Number: Enter your routing number which is printed on the bottom left hand portion of 
  your business checks. See Examples 1 and 2 below. Verify with your financial institution the correct routing 
  number to use for ACH deposits. Your financial institution may use different routing numbers for checks, 
  ACH deposits, and wire deposits.
 4.   Account Number: Enter your account number at your financial institution, which is printed on the bottom of 
  your business checks, following the routing number. It may be the first series of digits after the routing number, 
  followed by the check number (Example 1 below), or it may be the series of digits which follow the check number 
  (Example 2 below). The check number is not included in the depositor account number. (Include a voided check 
  or a letter from the financial institution as verification of the above information.)

 Example 1                                        Example 2

 XYZ Business                   Check No. 4444    XYZ Business                                    Check No. 4444
 Hometown, USA                                    Hometown, USA 

 Pay to the Order of                              Pay to the Order of

   123456789    8765432109812              4444     123456789              4444                 8765432109812
  
  Routing            Account               Check           Routing               Check            Account
  Number             Number                Number          Number                Number           Number

Please verify your company account name, ABA routing number, and account number with your financial institution.

Signature
We require two (2) authorized company official signatures. Include the official’s title.

Improper Completion
The form will be returned if the agreement:
 (1)  Does not contain two (2) authorized signatures, when applicable;
 (2)  Contains corrected errors (i.e., scratch-outs, white-out, type-over, etc.);
 (3)  Is not properly completed;
 (4)  Has an invalid account number or bank information; or
 (5)  Copy of voided check is not included.

Please return the completed agreement to the Missouri Department of Revenue, Taxation Division, at the address, 
fax number, or e-mail address shown on the form.  

                                *14000000001*
                                                  14000000001                                     Form 5378 (Revised 12-2023)