Form 4681 - Request From Record Holder

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MISSOURI DEPARTMENT OF REVENUE
FORM
4681
MOTOR VEHICLE AND DRIVER LICENSING DIVISION
REQUEST FROM RECORD HOLDER
(REV. 05-2013)
I hereby certify that my name is ___________________________________________________________________________.
(First Name)
(Middle Initial)
(Last Name)
I further certify that my date of birth is _________________, that my Missouri driver license number is ___________________,
(Month/Day/Year)
that my present mailing address is ________________________________________________________________________
(Street)
(Apartment/Unit)
(City)
(State)
(Zip Code)
and that my daytime telephone number is (___ ___ ___) ___ ___ ___ - ___ ___ ___ ___ .
(Include Area Code)
I am requesting the following records (including my personal information on those records):
MOTOR VEHICLE RECORDS: ________________________________
________________________________
Year-Make-VIN
Registration (Plate) Number
Title record (specify current or history)
Registration record (license plates)
Lienholder information
Other(specify) ________________
DRIVER LICENSE RECORDS:
Copy of application (specify year) _______
Image portfolio (black and white permit and license photo)
Driver record
Clearance letter (no fee required)
Other (specify) ____________________
Phone number (573) 751-2730
Temporary Driving Privilege_______ (duplicate license fee may apply)
PLEASE SEND THE REQUESTED RECORD(S) BY
MAIL
or
FAX (add $0.50 per page faxed)
PAYMENT OPTIONS
CENTRAL
TOTAL RECORD FEES CONVENIENCE FEE
Records can be
PAYMENT
FAX OR
MAIL
OFFICE
$0.00 - $33.00
$1.00
obtained by walk-in,
OPTIONS
E-MAIL
VISIT
mail-in, or e-mail
$33.01 - $100.00
3.00%
CASH
a
request.
$100.01 - $250.00
2.95%
a
CHECK
a
The fee is $5.88
$250.01 - $500.00
2.85%
MONEY ORDER
a
a
per record.
$500.01 - $750.00
2.85%
DEBIT CARD
a
a
a
$750.01 - $1,000.00
2.80%
A convenience fee
DISCOVER
a
a
will be charged for
a
VISA
a
a
$1,000.01 - $1,500.00
2.75%
credit and debit card
a
a
a
AMERICAN EXPRESS
$1,500.01 - $2,000.00
2.70%
transactions.
MASTERCARD
a
a
a
$2,000.01 or more
2.60%
Mail to: Motor Vehicle and Driver License Bureau-Record Center, PO Box 2167, Jefferson City, MO 65105-2167
Fax or E-Mail to: (573) 526-7367 dlrecords@dor.mo.gov
Visit at: Central Office, Harry S Truman Building, Room 370, 301 West High Street, Jefferson City, MO
If you are paying by credit or debit card you must provide the following:
NAME (AS IT APPEARS ON CARD)
CARD TYPE
CARD NUMBER
SECURITY CODE
EXPIRATION DATE
___ ___ ___
__ __ / __ __
I hereby authorize the Missouri Department of Revenue to
fax
mail this record information to:
Name: ___________________________________________ Fax: ( ___ ___ ___ ) ___ ___ ___ - ___ ___ ___ ___
Agency Name (if applicable) ____________________________________________________________________
Address: ____________________________________________________________________________________
RECORD HOLDER’S SIGNATURE
DATE (MM/DD/YYYY)
__ __ / __ __ / __ __ __ __
PRINTED NAME
NOTARY INFORMATION
STATE
COUNTY (OR CITY OF ST. LOUIS)
NOTARY PUBLIC EMBOSSER OR
BLACK RUBBER STAMP SEAL
SUBSCRIBED AND SWORN BEFORE ME, THIS
USE RUBBER STAMP IN CLEAR AREA BELOW.
DAY OF
YEAR
NOTARY PUBLIC SIGNATURE
MY COMMISSION
EXPIRES
NOTARY PUBLIC NAME (TYPED OR PRINTED)
THE MISSOURI DEPARTMENT OF REVENUE MAY ELECTRONICALLY RESUBMIT CHECKS RETURNED FOR INSUFFICIENT OR UNCOLLECTED FUNDS
For more information, visit
DOR-4681 (05-2013)

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