Form 4669 - Abandoned Property Report
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MISSOURI DEPARTMENT OF REVENUE
MOTOR VEHICLE BUREAU
PO BOX 2076, JEFFERSON CITY MO 65105-2076
FORM
(573) 526-3669
4669
ABANDONED PROPERTY REPORT
(REV. 9-2010)
(For tows from private property NOT authorized by law enforcement.)
I AUTHORIZE THE VEHICLE TO BE TOWED BASED ON THE REASON INDICATED BELOW.
CHECK A REASON:
1.
A SIGN NOT LESS THAN 17 X 22 INCHES IN SIZE CONTAINING LETTERING NOT LESS THAN ONE INCH IN HEIGHT IS DISPLAYED WITHIN PLAIN VIEW
PROHIBITING PUBLIC PARKING. I WILL NOTIFY THE LAW ENFORCEMENT AGENCY WITHIN 1 HOUR OF THE TOW.
2.
THE ABANDONED PROPERTY WAS LEFT UNATTENDED ON OWNER-OCCUPIED RESIDENTIAL PROPERTY WITH FOUR UNITS OR LESS. I HAVE
NOTIFIED THE _______________________________________________ LAW ENFORCEMENT AGENCY AND TEN HOURS HAVE ELAPSED SINCE THAT
NOTIFICATION.
THE ABANDONED PROPERTY WAS LEFT UNATTENDED ON PRIVATE PROPERTY. I HAVE NOTIFIED THE _______________________________________
3.
LAW ENFORCEMENT AGENCY AND NINETY-SIX HOURS HAVE ELAPSED SINCE THAT NOTIFICATION.
I CERTIFY THAT THE VEHICLE LISTED BELOW WAS ABANDONED ON PROPERTY OF WHICH I AM THE OWNER, LESSEE, OR PROPERTY/SECURITY MANAGER.
I HAVE AUTHORIZED THE TOWING COMPANY LISTED BELOW TO REMOVE THE VEHICLE FROM MY PROPERTY AND WITNESSED THE REMOVAL OF THE
VEHICLE. I FURTHER CERTIFY THAT ALL INFORMATION CONTAINED HEREIN IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE. I UNDERSTAND THIS
IS A LEGAL DECLARATION SUBJECT TO CRIMINAL PENALTIES.
SIGNATURE OF OWNER, LESSEE, OR PROPERTY/SECURITY MANAGER
PRINTED NAME OF OWNER, LESSEE, OR PROPERTY/SECURITY MANAGER
TELEPHONE NUMBER OF OWNER, LESSEE, OR PROPERTY/SECURITY MANAGER
DATE OF TOW
___ ___ / ___ ___ / ___ ___ ___ ___
(___ ___ ___) ___ ___ ___ - ___ ___ ___ ___
LOCATION OF ABANDONED PROPERTY TO BE TOWED (STREET ADDRESS, CITY, STATE, AND ZIP CODE)
NAME AND ADDRESS OF THE ABANDONED PROPERTY & OR DRIVER OWNER, IF KNOWN
NAME AND ADDRESS OF THE LIENHOLDER OF THE ABANDONED PROPERTY, IF KNOWN
DESCRIPTION OF DAMAGE TO THE ABANDONED PROPERTY
YEAR
MAKE
MODEL
VEHICLE IDENTIFICATION NUMBER
MILEAGE
LICENSE PLATE NUMBER
STATE
__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
__ __
STORAGE LOCATION OF THE ABANDONED PROPERTY
LAW ENFORCEMENT AGENCY NOTIFIED (MUST BE SAME AGENCY IN SECTION A)
DATE NOTIFIED
TIME NOTIFIED
___ ___ / ___ ___ / ___ ___ ___ ___
LAW ENFORCEMENT AGENCY ADDRESS
CITY
LAW ENFORCEMENT AGENCY
TELEPHONE NUMBER
(___ ___ ___) ___ ___ ___ - ___ ___ ___ ___
NAME OF TOWING COMPANY
TOWER HAS ONLINE ACCESS TO DOR RECORDS
TOWING COMPANY TELEPHONE
NUMBER
YES
NO
(___ ___ ___) ___ ___ ___ - ___ ___ ___ ___
ADDRESS OF TOWING COMPANY
CITY
STATE
ZIP CODE
___ ___ ___ ___ ___
NOTE: THIS REPORT MUST BE GIVEN TO THE LAW ENFORCEMENT AGENCY SHOWN ABOVE WITHIN 2 HOURS OF THE TOW
IF REASON 1 IS CHECKED ABOVE OR WITHIN TWENTY-FOUR HOURS FOR ALL OTHER TOWS.
SIGNATURE OF TOWING OPERATOR
PRINTED NAME OF TOWING OPERATOR
LAW ENFORCEMENT AGENCY
DATE NOTIFIED OF TOW
DATE REPORT FILED
___ ___ / ___ ___ / ___ ___ ___ ___
___ ___ / ___ ___ / ___ ___ ___ ___
INQUIRY DATE (MM/DD/YY)
NCIC (PROVIDE NUMBER) ___________________
MULES
REJIS
ALERT
OTHER
___ ___ / ___ ___ / ___ ___
MSHP NUMBER
REPORT/CASE/INCIDENT/TOW NUMBER
ABANDONED PROPERTY OWNER’S NAME
ADDRESS
CITY
STATE
ZIP CODE
__ __ __ __ __
LIENHOLDER’S NAME
ADDRESS
CITY
STATE
ZIP CODE
__ __ __ __ __
SIGNATURE OF OFFICER
PRINTED NAME OF OFFICER
BADGE
MO 860-2736 (9-2010)
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