Form 237 - Motor Vehicle Accident Release
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Missouri Department of Revenue
237
Motor Vehicle Accident Release
Case Number
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I, ________________________________ hereby forever release and discharge ___________________________________________,
any heirs, executors, administrators, and all firms, corporations, and persons on their behalf liable, from all claims, demands, damages,
actions, or causes of action arising from or growing out of, any and all personal injuries and property damage, now apparent as well as
those which may hereafter develop as a direct or indirect result of a collision which occurred
, at or near
___ ___ / ___ ___ / ___ ___ ___ ___
(MM/DD/YYYY)
__________________________________________________________________________________________Missouri.
Under penalties of perjury, I declare that the above information and any attached supplement is true, complete, and correct.
Printed Name of Person Giving Release
Signature
Date (MM/DD/YYYY)
___ ___ / ___ ___ / ___ ___ ___ ___
Subscribed and sworn before me, this
Embosser or black ink rubber stamp seal
day of
year
State
County (or City of St. Louis)
My Commission Expires
Notary Public Signature
Notary Public Name (Typed or Printed)
Additional Release of Parent or Guardian For Injuries to Minor Child
I, ___________________________________, state that I am the parent or guardian of __________________________________,
a minor under 18 years of age, and that the above release is made at my request and that I make this release for said minor child,
and that I agree to hold harmless any person against any action, claim or demand for said minor child or any other person for
injuries or damages to said minor child.
Under penalties of perjury, I declare that the above information and any attached supplement is true, complete, and correct.
Printed Name of Person Giving Release
Signature
Date (MM/DD/YYYY)
___ ___ / ___ ___ / ___ ___ ___ ___
Subscribed and sworn before me, this
Embosser or black ink rubber stamp seal
day of
year
State
County (or City of St. Louis)
My Commission Expires
Notary Public Signature
Notary Public Name (Typed or Printed)
Form 237 (Revised 06-2013)
Mail to:
Driver License Bureau
Phone: (573) 751-7195
Visit dor.mo.gov/drivers/ for
301 West High Street - Room 470
Fax:
(573) 526-7365
additional information.
P.O. Box 200
E-mail: dlbmail@dor.mo.gov
Jefferson City, MO 65105-0200
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