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Please complete this form and return using one of the methods listed below. Select one box for the appropriate tax type.
Sales and Use Tax
Taxation Division
P.O. Box 3350
Jefferson City, MO 65105-3350
Phone: (573) 526-9938
Fax: (573) 751-9409
Motor Fuel Tax
Taxation Division
P.O. Box 300
Jefferson City, MO 65105-0300
Phone: (573) 751-2611
Fax: (573) 522-1720
E-mail: [email protected]
Cigarette Tax and Other
Tobacco Products Tax
Taxation Division
P.O. Box 811
Jefferson City, MO 65105-0811
Phone: (573) 751-7163
Fax: (573) 522-1720
Financial Institutions and
Insurance Taxes
Taxation Division
P.O. Box 898
Jefferson City, MO 65105-0898
Phone: (573) 751-2326
Fax: (573) 522-1721
Withholding Tax
Taxation Division
P.O. Box 3375
Jefferson City, MO 65105-3375
Phone: (573) 751-8750
Fax: (573) 522-6816
Corporate Tax
Taxation Division
P.O. Box 3365
Jefferson City, MO 65105-3365
Phone: (573) 751-4541
Fax: (573) 522-1721
E-mail: [email protected]
Business Tax Registration Bond
Taxation Division
P.O. Box 357
Jefferson City, MO 65105-0357
Phone: (573) 751-5860
Fax: (573) 522-1722
E-mail: [email protected]
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Type of Agreement (Select One) Tax Period
Name
Address City State ZIP Code
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Company or Individual (Payee) Information
*14501010001*
14501010001
Form
5378
Agreement to Receive Refund by ACH Transfer
Missouri Tax I.D.
Number
Federal Employer
I.D. Number
r Individual or Partnership Tax
Taxation Division
P.O. Box 2200
Jefferson City, MO 65105-2200
Phone: (573) 751-3505
Fax: (573) 522-1762
Primary Taxpayer
Social Security
Secondary Taxpayer
Social Security
Number Number
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Pass-Through Entity Tax
Taxation Division
P.O. Box 3080
Jefferson City, MO 65105-3080
Phone: (573) 751-5860
Fax: (573) 522-1721
Fiduciary Tax
Taxation Division
P.O. Box 3815
Jefferson City, MO 65105-3815
Phone: (573)751-1467
Fax: (573) 522-1762
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Reset Form
Print Form
*14501020001*
14501020001
Signature Title Date (MM/DD/YYYY)
Department Use Only
__ __ /__ __ /__ __ __ __
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)
(__ __ __) __ __ __ - __ __ __ __ (__ __ __) __ __ __ - __ __ __ __ __ __ /__ __ /__ __ __ __
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.
Ever served on active duty in the United States Armed Forces?
If yes, visit dor.mo.gov/military/ to see the services and benets we offer to all eligible
military individuals. A list of all state agency resources and benets can be found at
veteranbenets.mo.gov/state-benets/.
Company Official/Secondary Taxpayer Signature Company Official/Secondary Taxpayer Printed Name
Title E-mail Address
Telephone Number Fax Number Date Signed (MM/DD/YYYY)
(__ __ __) __ __ __ - __ __ __ __ (__ __ __) __ __ __ - __ __ __ __ __ __ /__ __ /__ __ __ __
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.
Financial Institution (Banking) Information
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.)
Form 5378 (Revised 02-2024)
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
