Form 1062 - Affidavit For Mechanic Lien Title
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Form
Missouri Department of Revenue
1062
Affidavit for Mechanic Lien Title
I certify that the motor vehicle, trailer, all-terrain vehicle, manufactured home, vessel, or outboard motor listed below is in my
possession and that the owner of said unit has defaulted in payment. The total amount of repair and storage that is noted below
has not been paid as evidenced by the attached work order or storage bill. The owner and lienholder listed below were notified
of this debt by certified mail on the date noted. Copies of the notification letter(s) and the certified mail card(s) have been
submitted with this affidavit. Neither the owner nor the lienholder has paid, or made satisfactory arrangements for payment of,
storage or service towing charges within 30 days since notification of my intent to title the unit. See requirements on reverse.
Year
Make
Vehicle or Manufacturer’s Identification Number
Amount of Repair or Storage
$
__ __ __ __
Titled Owner’s Name
Number of Months Payment Overdue (minimum of 45 days)
Owner’s Address
City
State
Zip Code
Name of Vehicle Owner’s Lienholder
Street Address
City
State
Zip Code
Name of Mechanic or Garage
Street Address
City
State
Zip Code
Date Owner Notified by Certified Mail (MM/DD/YYYY)
Signature of Applicant
__ __ /__ __/__ __ __ __
Embosser or black ink rubber stamp seal.
Subscribed and sworn before me, this
day of
year
State
County (or City of St. Louis)
My Commission Expires
Notary Public Signature
Notary Public Name (Typed or Printed)
r
Have you included:
Completed application
r
Completed affidavit
r
Signed work order, storage agreement, or tow agreement
r
Signed certified mail notification or unclaimed returned envelope
r
Titling fees and processing fees
Form-1062 (Revised 06-2013)
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