Form 5062 - Application For Vehicle/trailer Identification Number Plate Or Verification
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MISSOURI DEPARTMENT OF REVENUE
CONTROL NO.
FORM
MOTOR VEHICLE BUREAU
5062
APPLICATION FOR VEHICLE/TRAILER IDENTIFICATION
NUMBER PLATE OR VERIFICATION
(REV. 8-2012)
SEE INSTRUCTIONS ON REVERSE
INSTRUCTIONS:
VALIDATION ONLY
Step 1: Applicant must complete and sign Section A.
Step 2: If a replacement vehicle identification number (VIN) is required,
Section B must be notarized by a notary public.
Step 3: Submit your motor vehicle/trailer and this form to authorized law
enforcement as designated on the reverse side of this form.
Step 4: Submit the completed form to the Department of Revenue as
Office Use Only — New ID:
noted on the reverse side of this form.
SECTION A — APPLICANT
PURPOSE OF INSPECTION: (Check one):
TITLE CORRECTION OR VEHICLE VIN VERIFICATION
NEW IDENTIFICATION NUMBER PLATE
REPLACEMENT IDENTIFICATION NUMBER PLATE
TRAILER WITH A SALVAGE TITLE
UNIT: (Check one):
MOTOR VEHICLE
MANUFACTURED TRAILER
HOMEMADE TRAILER (16 FEET OR MORE)
REGISTERED OWNER (LAST, FIRST, MIDDLE)
DEALER NUMBER
COUNTY
DAYTIME TELEPHONE NUMBER
__ __ __ __ __
(_ _ _) _ _ _ - _ _ _ _
STREET, RR, OR P.O. BOX NUMBER
CITY
STATE
ZIP CODE
MO
__ __ __ __ __
MOTOR VEHICLE/TRAILER
YEAR
MAKE
VEHICLE IDENTIFICATION NUMBER
MISSOURI TITLE NUMBER
LICENSE NUMBER
__ __
BODY STYLE
MODEL
COLOR
CYLINDERS
H.P.
MILEAGE
COMPLETE THE INFORMATION BELOW IF APPLYING FOR A REPLACEMENT VIN — APPLICATION MUST ALSO BE NOTARIZED
LOSS OF VIN. PLATE REPORTED TO:
DATE
REASON REQUIRED
_ _/_ _/_ _ _ _
LOST
STOLEN
MUTILATED
DESTROYED
APPLICANT’S SIGNATURE
I certify that the statements above are true and that I am the registered
owner of the above described unit(s).
SIGNATURE
SECTION B — NOTARY PUBLIC
NOTARY PUBLIC EMBOSSER OR
STATE
COUNTY (OR CITY OF ST. LOUIS)
BLACK INK RUBBER STAMP SEAL
SUBSCRIBED AND SWORN BEFORE ME, THIS
USE RUBBER STAMP IN CLEAR AREA BELOW.
DAY OF
YEAR
NOTARY PUBLIC SIGNATURE
MY COMMISSION
EXPIRES
NOTARY PUBLIC NAME (TYPED OR PRINTED)
SECTION C — FOR AUTHORIZED LAW ENFORCEMENT AGENCY USE ONLY — DO NOT WRITE BELOW THIS LINE
CYLINDERS
H.P.
I certify that on _____________ I physically inspected the above described vehicle/trailer after the applicant
provided satisfactory proof of ownership and found the identification number(s) as recorded below.
YEAR
MAKE
BODY STYLE
MILEAGE
ENGINE VIN (FOR MODEL YEARS PRIOR TO 1957)
PUBLIC VIN
The VIN plate listed below must be surrendered
at the time a new replacement number is issued.
POLICE VIN
_________________________________
REPLACEMENT VIN REQUIRED
NEW VIN REQUIRED — IF A TRAILER: UNIT IS:
HOMEMADE MORE THAN 16 FEET
MANUFACTURED TRAILER
NO NEW/REPLACEMENT VIN REQUIRED
TYPE OF TRAILER _______________________________________________ NO OF AXLES ________________ LENGTH ______________
CONDITION OF UNIT:
WRECKED
SALVAGED
RUNNING
REBUILT
MOTOR CHANGE
OTHER ____________________________________________________
REMARKS AND DISCREPANCIES NOTED
LAW ENFORCEMENT AGENCY
FILE NUMBER
EXAMINING OFFICER’S SIGNATURE
TELEPHONE NUMBER
BADGE NO.
(_ _ _) _ _ _ - _ _ _ _
TO BE COMPLETED BY AUTHORIZED LAW ENFORCEMENT WHEN A DR NUMBER OR REPLACEMENT VIN PLATE IS AFFIXED.
I certify that on _____________ I did affix the new/replacement VIN plate, control number ______________________________ issued by the Department
of Revenue to the above vehicle.
The outstanding VIN plate listed above has been surrendered and forwarded to the Missouri State Highway Patrol, Auto Theft Unit.
LAW ENFORCEMENT AGENCY
LAW ENFORCEMENT OFFICER’S SIGNATURE
BADGE NO.
DOR-5062 (8-2012)
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