Form 5450 - Authorization For Release Of Motor Vehicle Dealer Confidential Information
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MISSOURI DEPARTMENT OF REVENUE
FORM
5450
AUTHORIZATION FOR RELEASE OF MOTOR VEHICLE
DEALER CONFIDENTIAL INFORMATION
(REV. 1-2013)
Dealer Name (as indicated on the dealer license): _______________________________________________
Dealer Number: __________________________________________________________________________
I am a principal who is an officer authorized to bind for all purposes the motor vehicle dealer identified above or I am the owner of
the motor vehicle dealership identified above.
I hereby authorize and request the Department of Revenue to release the following information contained in the Department’s
records pertaining to the above referenced dealer license (must check one of the following):
All information; or
Information pertaining to the specific licensure year (s) of : _____________________________.
The information authorized to be released in accordance with this request is authorized to be released only to the following
individual or entity:
Individual or Entity Name: __________________________________________________________________
This authorization shall be effective the date of this signing and shall remain in effect until revoked by an authorized representa-
tive of the motor vehicle dealer providing such authorization.
Disclaimer: I hereby agree to release, waive and discharge any claims whatsoever, including claims of negligence, that have or
may arise against the Department of Revenue, its director, agents or employees from any and all liability or damages related to
the authorized or unauthorized disclosure of information, including confidential information as that information may be described
by state or federal law.
Under penalties of perjury, I declare that I have examined this authorization, and, to the best of my knowledge, it is true, correct,
and complete.
Under penalties of perjury, I further declare that I have the authority to make such declarations on behalf of the motor vehicle
dealer identified on this release.
SIGNATURE
DATE
__ __ / __ __ / __ __ __ __
PRINTED NAME
RELATIONSHIP TO THE DEALER (I.E., OWNER, PRESIDENT, ETC.)
NOTARY INFORMATION
NOTARY PUBLIC EMBOSSER SEAL
STATE
COUNTY (OR CITY OF ST. LOUIS)
SUBSCRIBED AND SWORN BEFORE ME, THIS
DAY OF
YEAR
USE RUBBER STAMP IN CLEAR AREA BELOW.
NOTARY PUBLIC SIGNATURE
MY COMMISSION
EXPIRES
NOTARY PUBLIC NAME (TYPED OR PRINTED)
DOR-5450 (1-2013)
This publication is available upon request in alternative accessible format(s).
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