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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
MO
®
$
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
X
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
MY COMMISSION EXPIRES
NOTARY PUBLIC NAME (TYPED OR PRINTED)
DOR-5005 (09-2011)