Form 2510 - Application For Repossessed Placard(S)
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MISSOURI DEPARTMENT OF REVENUE
FORM
MOTOR VEHICLE BUREAU-DEALER LICENSING SECTION
2510
APPLICATION FOR REPOSSESSED PLACARD(S)
(REV. 5-2008)
VALIDATION ONLY
NUMBER OF PLACARD(S) REQUESTED
REPOSSESSED PLACARD NUMBER(S) ASSIGNED
BUSINESS NAME
TELEPHONE NUMBER
( __ __ __ ) __ __ __ - __ __ __ __
STREET ADDRESS OR RFD
COUNTY
CITY
STATE
ZIP CODE
__ __ __ __ __ - __ __ __ __
I hereby certify that the information given herein is correct and that the placard(s) applied for will be used in accordance with the laws of the
State of Missouri. The signature below shall certify that I have and will maintain, during the period of registration, financial responsibility with
respect to each motor vehicle that I own, license or operate on the streets or highways.
SIGNATURE OF APPLICANT
DATE
__ __ /__ __ /__ __ __ __
IF REPLACEMENT PLACARD(S) IS/ARE NEEDED, COMPLETE THE FOLLOWING:
REASON REQUIRED
LOST
STOLEN
MUTILATED
DESTROYED
LIST REPOSSESSED PLACARD(S) TO BE REPLACED:
PLACARD NUMBER
NEW PLACARD NUMBER
PLACARD NUMBER
NEW PLACARD NUMBER
PLACARD NUMBER
NEW PLACARD NUMBER
PLACARD NUMBER
NEW PLACARD NUMBER
PLACARD NUMBER
NEW PLACARD NUMBER
PLACARD NUMBER
NEW PLACARD NUMBER
PLACARD NUMBER
NEW PLACARD NUMBER
PLACARD NUMBER
NEW PLACARD NUMBER
NOTARY
NOTARY PUBLIC EMBOSSER SEAL
STATE OF
COUNTY (OR CITY OF ST. LOUIS)
SUBSCRIBED AND SWORN BEFORE ME, THIS
DAY OF
YEAR
USE RUBBER STAMP IN CLEAR AREA BELOW.
NOTARY PUBLIC SIGNATURE
MY COMMISSION
EXPIRES
NOTARY PUBLIC NAME (TYPED OR PRINTED)
“Any false statement is a violation of the law and may be punished by fine, imprisonment or both.” (301.420 RSMo)
MO 860-0381 (5-08)
DISTRIBUTION: WHITE - OFFICE;
PINK - APPLICANT;
YELLOW - AUDIT
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