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Candidate Information

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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*

Print Form

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


Street Address*


Elected Office Candidate is Seeking

E-mail Address


Zip Code

Notary Information


* Please update the Department should any information change

Declaration under 115.306, RSMo: I hereby declare under penalties of perjury that I am not currently aware
of any delinquency in the filing 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 officer of any fee office that owes any taxes to the state, other than those taxes
which may be in dispute. I declare under penalties