Form 5314 - Application For Confirmation Of Conversion
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FORM
MISSOURI DEPARTMENT OF REVENUE
5314
MOTOR VEHICLE BUREAU
APPLICATION FOR CONFIRMATION OF CONVERSION
(REV. 02-2011)
OWNER NAME
RESIDENTIAL ADDRESS
MAILING ADDRESS
CITY
STATE
ZIP
MANUFACTURED HOME INFORMATION
NAME OF MANUFACTURER
DIMENSIONS OF THE HOME
DATE OF PURCHASE
HOME IS:
NEW
USED
MODEL YEAR
MAKE
MODEL NAME
MANUFACTURER’S SERIAL NUMBER OF THE MANUFACTURED HOME
PURCHASE PRICE OR DECLARED VALUE OF THE MANUFACTURED HOME
_____________________________________________
PREVIOUS OWNER INFORMATION
PREVIOUS OWNER’S NAME AND STREET ADDRESS
CITY
STATE
ZIP
STATEMENT OF FACTS REGARDING CERTIFICATE OF TITLE
I HEREBY STATE THE FOLLOWING: (PLACE INITIALS IN APPLICABLE BOXES)
The following facts are known by me which affect the validity of the title to the manufactured home referenced above (attach a separate
exhibit if more space is needed).
___________________________________________________________________________________________________
I am not aware of any facts or information that could affect the validity of the title of the manufactured home or the existence or nonexistence
of a security interest in or lien on it.
LIENHOLDER(S) INFORMATION
(IN ORDER OF PRIORITY)
LIENHOLDER NAME
ADDRESS
LIENHOLDER NAME
ADDRESS
PARTIES REQUESTING WRITTEN ACKNOWLEDGEMENT OF CONVERSION
NAME
ADDRESS
NAME
ADDRESS
Under the penaltes of perjury, I hereby affirm that the information contained in this application is true and accurate.
______________________________________________________
____________________________________________________
__________________
APPLICANT’S SIGNATURE
PRINTED NAME
DATE
STATE
COUNTY (OR CITY OF ST. LOUIS)
NOTARY SEAL
SUBSCRIBED AND SWORN BEFORE ME, THIS
DAY OF
NOTARY PUBLIC SIGNATURE
MY COMMISSION EXPIRES
NOTARY PUBLIC NAME (TYPED OR PRINTED)
TO BE COMPLETED BY AN ATTORNEY-AT-LAW OR AN AGENT OF A TITLE INSURANCE COMPANY
I certify that the manufactured home described in this Application for Confirmation of Conversion is free and clear of, or has been released from,
all recorded security interests, liens, and encumbrances.
PLACE YOUR INITIALS IN ONE OF THE APPLICABLE BOXES BELOW:
I certify 1) that the following facts are known to me that could affect the validity of the certificate of title to the manufactured home described
in this application, or 2) that I am aware of the existence of the following lien or encumbrance to the manufactured home described in this
application (attach separate exhibit if more space is needed):
____________________________________________________________________________________________________
OR,
I am not aware of any facts or information which may affect the validity of the certificate of title to, or the existence of any lien or
encumbrance on the manufactured home described in this application.
____________________________________________________________________________________________________
Bar Number if an Attorney _____________________________
License Number if a Title Insurance Agent _____________________________
Signature of Attorney or Title Insurance Agent
Typed or Printed Name
Date
DOR-5314 (02-2011)
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