Form 1600 - Statement Of Non-Involvement
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Missouri Department of Revenue
Form
1600
Statement of Non-Involvement
Case Number
I, ____________________________________, hereby state that I was not in any manner involved in a motor vehicle accident,
either as vehicle operator or owner,
r
A.M.
Of a (Vehicle Make, Year, Model)
On the
Time
r
P.M.
Day of
Year
On (Street or Highway)
Or Near (Town or City)
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 1600 (Revised 06-2013)
Mail to:
Driver License Bureau
Phone: (573) 751-7195
Visit dor.mo.gov/drivers/
301 West High Street - Room 470 Fax:
(573) 526-7365
for additional information.
P.O. Box 200
E-mail: dlbmail@dor.mo.gov
Jefferson City, MO 65105-0200
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