Form 1500 - Statement Of Vehicle Taken Without Permission
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Form
Missouri Department of Revenue
1500
Statement of Vehicle Taken Without Permission
Case Number
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The following registered owner(s) ______________________________________________________________________ of
a _____________________________ hereby states that this automobile was taken and driven on __ __ / __ __ / __ __ __ __,
Vehicle Year, Make and Model
(MM/DD/YYYY)
r
r
_______
A.M.
P.M. without my (our) permission, either written or oral. The owner(s) denies any responsibility for the
accident involving this automobile on __ __ / __ __ / __ __ __ __ at or near ______________________________, Missouri.
(MM/DD/YYYY)
Under penalties of perjury, I declare that the above information and any attached supplement is true, complete, and correct.
Signature
Driver License Number
Date (MM/DD/YYYY)
___ ___ / ___ ___ / ___ ___ ___ ___
Address
City
State
Zip Code
Form 1500 (Revised 05-2013)
Mail to:
Driver License Bureau
Phone: (573) 751-7195
Visit dor.mo.gov/drivers/
301 West High Street
Fax:
(573) 526-7365
for additional information.
P.O. Box 200
Email: dlbmail@dor.mo.gov
Jefferson City, MO 65105-0200
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