Form 2635 - Affidavit Of Ownership

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MISSOURI DEPARTMENT OF REVENUE
FORM
MOTOR VEHICLE BUREAU
2635
AFFIDAVIT OF OWNERSHIP
(REV. 04-2011)
INSTRUCTIONS
“Any false statement in this application is a violation of the law and may be punished by fine or imprisonment or both”
1. This affidavit is to be completed only when you are making application for a duplicate certificate of title for a
motor vehicle or trailer, which was originally titled in the State of Missouri between the years of 1948 and 1969.
2. Complete this form in full.
3. Submit this form and $11.00 ($8.50 title fee; $2.50 processing fee) to any license office or mail to: MISSOURI
DEPARTMENT OF REVENUE, MOTOR VEHICLE BUREAU, PO BOX 100, JEFFERSON CITY MO 65105-0100. If you
have any questions, please call (573) 526-3669. Visit our web site at
I hereby make application for duplicate title on the motor vehicle/trailer described below. I verify that the vehicle
was last titled in the State of Missouri in my name and that the original title has been lost, stolen, mutilated,
or destroyed.
OWNER’S NAME (LAST, FIRST, MIDDLE)
TELEPHONE
(
)
STREET ADDRESS, RR OR P.O. BOX NUMBER
COUNTY
CITY
STATE
ZIP CODE
MOTOR VEHICLE/TRAILER INFORMATION
YEAR
MAKE
VEHICLE IDENTIFICATION NUMBER
MILEAGE
CYLINDER
H.P.
KIND OF VEHICLE
PREVIOUS TITLE NUMBER
PREVIOUS LICENSE NUMBER PURCHASE DATE (MO/DAY/YR)
CHECK ONE BOX ONLY:
1. The lien on the vehicle shown on the original certificate of title has been released.
The notarized lien release is attached.
2. No lien was shown on the vehicle on the original certificate of title.
3. There is a lien currently on the vehicle as shown on the attached application for title.
I HEREBY STATE ALL FACTS CONTAINED HEREIN ARE TRUE TO THE BEST
OF MY KNOWLEDGE.
OWNER’S SIGNATURE
NOTARY INFORMATION REQUIRED
STATE
SUBSCRIBED AND SWORN BEFORE ME THIS
DAY OF
NOTARY PUBLIC NAME (TYPE OR PRINT)
NOTARY PUBLIC SIGNATURE
MY COMMISSION
EXPIRES
NOTARY PUBLIC EMBOSSER SEAL
COUNTY (OR CITY OF ST. LOUIS)
USE RUBBER STAMP IN CLEAR AREA BELOW.
MO 860-1649 (04-2011)

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