Voluntary Disclosure Form

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.

Has the applicant contacted or been contacted by Missouri or the Multistate Tax Commission concerning unpaid taxes?

Yes

No

Which type(s) of tax is the applicant currently registered for and filing in Missouri?

Sales

Vendor's Use

Consumer's Use

Corporation Income

Corporation Franchise

Withholding

Fiduciary

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

Sales

Vendor's Use

Consumer's Use

Corporation Income

Corporation Franchise

Withholding

Fiduciary

Individual

What years does the oversight encompass.

what taxes have been collected but not remitted?

Sales

Vendor's Use

None

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

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

Name

First

Last

Title

Company

Address

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Voluntary Disclosure Agreement

Applicant Information

Individual, Entity, or Representative Information