Form 5091 - Request For Motor Vehicle/driver License Records/personal Information Page 2
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SECTION C. REQUEST TO OBTAIN MISSOURI VEHICLE INFORMATION
VEHICLE OWNER’S NAME — LAST, FIRST, MIDDLE INITIAL
VEHICLE OWNER’S STREET ADDRESS, R.R., OR P.O. BOX NUMBER
CITY
STATE
ZIP CODE
MOTOR VEHICLE
MARINE
YEAR
MAKE
TITLE NUMBER
YEAR
MAKE
DECAL NUMBER
EXPIRATION YEAR
1
1
VEHICLE IDENTIFICATION NUMBER
IDENTIFICATION NUMBER
LICENSE PLATE NUMBER
EXPIRATION YEAR
ADDITIONAL INFORMATION
YEAR
MAKE
TITLE NUMBER
YEAR
MAKE
DECAL NUMBER
EXPIRATION YEAR
2
2
VEHICLE IDENTIFICATION NUMBER
IDENTIFICATION NUMBER
LICENSE PLATE NUMBER
EXPIRATION YEAR
ADDITIONAL INFORMATION
CHECK INFORMATION TYPE
:
(RECORDS MAY BE CERTIFIED)
CURRENT OWNER/LIENHOLDER - Requester will receive only the name and address of the latest owner and lienholder when applicable on file.
TITLE HISTORY - Requester will receive a list that shows each time the ownership changed in this state, including the names and addresses of the owners.
MILEAGE HISTORY - Requester will receive a list that shows each time the ownership changed in this state, including the mileage, title numbers, and issue dates.
NAME HISTORY - Requester will receive a list of the current vehicles registered in the owner’s name.
SECTION D. REQUEST TO OBTAIN MISSOURI DRIVER RECORD INFORMATION
NAME OF RECORD HOLDER— LAST, FIRST, MIDDLE INITIAL
MISSOURI DRIVER LICENSE NUMBER
SOCIAL SECURITY NUMBER
DATE OF BIRTH
I HEREBY REQUEST THE FOLLOWING RECORD (PLEASE MARK THE APPROPRIATE BOX(ES):
THE FEE IS $5.88 PER RECORD.
DRIVER RECORD*
IMAGE PORTFOLIO (LICENSE PHOTO)
CASE HISTORY*
HARDSHIP PACKAGE __________________________________________
A CASE HISTORY CONSISTS OF ANY OPEN CASE OR ANY REINSTATEMENT
A HARDSHIP PACKAGE CONSISTS OF A CERTIFIED DRIVER RECORD AND A CERTIFIED SR-22.
OR TERMINATION CASE NOT LESS THAN TWO YEARS OLD.
OTHER (SPECIFY) _____________________________________________
CASE DOCUMENT (SPECIFY)*
REINSTATEMENT NOTICE
_____________________________________________________________
SUSPENSION NOTICE
_____________________________________________________________
CONVICTION (TICKET# ____________________)
*RECORDS MAY BE CERTIFIED
SR-22
PLEASE SEND THE ABOVE RECORD(S) BY
MAIL
and/or
FAX (add $0.50 per page faxed)
CHECK IF CERTIFIED RECORD REQUESTED
PAYMENT OPTIONS
TOTAL RECORD FEES CONVENIENCE FEE
CENTRAL
PAYMENT
FAX OR
Records can be
MAIL
OFFICE
$0.00 - $33.00
$1.00
obtained by walk-
OPTIONS
E-MAIL
VISIT
$33.01 - $100.00
3.00%
in, mail-in, or e-mail
CASH
a
request.
$100.01 - $250.00
2.95%
CHECK
a
a
$250.01 - $500.00
2.85%
The fee is $5.88
MONEY ORDER
a
a
per record.
$500.01 - $750.00
2.85%
DEBIT CARD
a
$750.01 - $1,000.00
2.80%
DISCOVER
a
a
a
A convenience fee
$1,000.01 - $1,500.00
2.75%
a
a
a
VISA
will be charged for
credit/debit card
a
a
a
$1,500.01 - $2,000.00
2.70%
AMERICAN EXPRESS
transactions.
MASTERCARD
a
a
a
$2,000.01 or more
2.60%
Mail to: Motor Vehicle and Driver License Bureau-Record Center, PO Box 2167, Jefferson City, MO 65105-2167
Fax or E-Mail to: (573) 526-7367 dlrecords@dor.mo.gov
Visit at: Central Office, Harry S Truman Building, Room 360, 301 West High Street, Jefferson City, MO
If you are paying by credit/debit card you must provide the following:
NAME (AS IT APPEARS ON CARD)
CARD TYPE
CARD NUMBER
EXPIRATION DATE
__ __ / __ __
REQUESTER’S SIGNATURE
PRINTED NAME
THE MISSOURI DEPARTMENT OF REVENUE MAY ELECTRONICALLY RESUBMIT CHECKS RETURNED FOR INSUFFICIENT OR UNCOLLECTED FUNDS
DOR-5091 (05-2013)
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