Fillable Form 5005 - Application/affidavit For Missouri Repossession Title printable pdf download

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ANY FALSE STATEMENT IN THIS APPLICATION IS A VIOLATION OF THE LAW AND MAY BE

PUNISHED BY FINE OR IMPRISONMENT OR BOTH.

DOR USE ONLY-REJECT NUMBER

STAPLE

HERE

BRAND CODE

TYPE ALL APPLICATIONS - QUESTIONS SHOULD

BE REFERRED TO (573) 526-3669.

MISSOURI DEPARTMENT OF REVENUE

MOTOR VEHICLE BUREAU

OFFICE VALIDATION

PO BOX 2076, JEFFERSON CITY MO 65105-2076

FORM

(573) 526-3669

5005

APPLICATION/AFFIDAVIT FOR MISSOURI

(REV. 09-2011)

REPOSSESSION TITLE

IF UNIT WAS TOWED, RECORD THE NAME OF THE LAW

MOTOR

MANUFACTURED

BOAT/VESSEL/

TRAILER

ENFORCEMENT AGENCY THE VEHICLE WAS REPORTED TO:

VEHICLE

HOME

OUTBOARD MOTOR

LIENHOLDER NAME

STREET ADDRESS, R.R. OR P.O. BOX NUMBER

CITY, STATE, ZIP CODE

TELEPHONE NUMBER

REPO. TITLE FEES

(

)

$10 REPO. TITLE

YEAR

MAKE

UNIT IDENTIFICATION NUMBER

(IF TYPING, DISREGARD BLOCK CONSTRAINTS)

BODY STYLE

$2.50 PROCESSING

FUEL

DEBTOR’S TITLE NO.

STATE

CURRENT MILEAGE

CODE

REPOSSESSION DATE

G - GAS

P - PROPANE

FEE

OF UNIT

D - DIESEL

E - ELECTRIC

N - NATURAL O - OTHER

KIND OF VEHICLE

KIND OF VEHICLE (K.O.V.)

CYLINDER

HORSEPOWER

$5 QUICK

MODEL NUMBER

P - PASSENGER

M - MOTORCYCLE

FEE

T - TRUCK

C - TRICYCLE

D - TRAILER/MANF. HOME R - REC. VEHICLE

B - BUS

A - ATV

COLOR

LENGTH

MATERIAL

BOAT TYPE

TYPE OF PROPULSION

TAX EXEMPT (#13)

FT.

IN.

TOTAL

BOAT / VESSEL LICENSE ID NUMBER

TYPE OF USE (CHECK ONE)

IF MISSOURI TITLE FILL IN FIRST

FOUR LETTERS OF PREVIOUS

PLEASURE

RENTAL

COMMERCIAL

OWNER’S LAST NAME

MAIL TITLE TO ADDRESS BELOW IF DIFFERENT FROM APPLICANT’S ADDRESS

NAME

STREET ADDRESS, R.R., OR P.O. BOX NUMBER

CITY, STATE, ZIP CODE

DEBTOR’S NAME

STREET ADDRESS, R.R., OR P.O. BOX NUMBER

CITY, STATE, ZIP CODE

STREET OR PHYSICAL ADDRESS OF THE UNIT LOCATION

CITY, STATE, ZIP CODE

I certify under penalties of perjury that the debtor has defaulted in payment of the debt on the unit listed above and the unit has been repossessed either by legal

process or in accordance with the terms of the security contract. I have written consent from all owners and/or lienholders of record to repossess this unit or I have

provided all owners/lienholders with a 10-day written notice by first class mail or as outlined in the Uniform Commercial Code, of the repossession and that an

application for repossessed title will be made and the notice has now expired. If the unit being

SIGNATURE OF LIENHOLDER’S REPRESENTATIVE (REQUIRED)

repossessed is a manufactured home, I further affirm that as the holder of such manufactured

home, I have paid all rent accrued to the owner of any real property where such rent is

obligated to be paid pursuant to the provisions of section 700.529, RSMo, if applicable.

NOTARY PUBLIC EMBOSSER

STATE

COUNTY (OR CITY OF ST. LOUIS)

OR BLACK RUBBER STAMP SEAL

SUBSCRIBED AND SWORN BEFORE ME, THIS

DAY OF

NOTARY PUBLIC SIGNATURE