Form 4201 - Affidavit For Assignment Of Securities
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Missouri Department of Revenue
4201
Affidavit for Assignment of Securities
I, ________________________________________________ , hereby assign all rights of the attached certificate
number _______________________________ , to the Department of Revenue, State of Missouri, until cancelled.
Acknowledgement (Must be completed by bank official.)
I, ____________________________________________ , hereby acknowledge that the assignment of certificate
number _____________________________ is valid and _____________________________________ is aware
(Name of Bank)
of said assignment.
Bank Official’s Name and Title
Address
Phone Number
( ___ ___ ___ ) ___ ___ ___ - ___ ___ ___ ___
City
State
Zip Code
I, ______________________________________________ , hereby assign and transfer to the Department of
Revenue, State of Missouri, my rights of ownership on the securities listed a ___________________________ ,
represented by identifying number ____________________________________________ , to cover the sum
of $60,000 should the occasion arise.
Additional collateral will be added should the market price of the pledged securities fall below the required deposit
of $60,000.
Under penalties of perjury, I declare that the above information and any attached supplement is true, complete, and correct.
Signature
Printed Name
Address
Date (MM/DD/YYYY)
___ ___ / ___ ___ / ___ ___ ___ ___
Subscribed and sworn before me, this
Embosser or black ink rubber stamp seal
day of
year
State
County (or City of St. Louis)
My Commission Expires
Notary Public Signature
Notary Public Name (Typed or Printed)
Form 4201 (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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Parent category: Financial