Form 1210 - Installment Agreement
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Missouri Department of Revenue
1210
Installment Agreement
Case Number __________________________________________
City or County of Accident
State of Accident
Accident Date (MM/DD/YYYY)
___ ___ / ___ ___ / ___ ___ ___ ___
Damaged Party
Person Receiving Payment
Total Amount Owed
Monthly Payment Amount
Date of First Payment
Final Payment Date
___ ___ / ___ ___ / ___ ___ ___ ___
___ ___ / ___ ___ / ___ ___ ___ ___
Driver’s Driver License Number
Driver’s Date of Birth
___ ___ / ___ ___ / ___ ___ ___ ___
Owner’s Driver License Number (if different from driver)
Owner’s Date of Birth (if different from driver)
___ ___ / ___ ___ / ___ ___ ___ ___
Under penalties of perjury, I declare that the above information and any attached supplement is true, complete, and correct. I or We
the undersigned, hereby agree to effect settlement of a claim for damages and/or personal injuries suffered by the damaged party.
Driver’s Signature (Party Agreeing to Pay)
Owner’s Signature, if different from Driver (Party Agreeing to Pay)
Date (MM/DD/YYYY)
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)
Under penalties of perjury, I declare that the above information and any attached supplement is true, complete, and correct. I or We, the
undersigned, accept the above agreement.
Signature (Party Receiving Payment)
Signature (Party Receiving Payment)
Date (MM/DD/YYYY)
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)
Under the Missouri Financial Responsibility Law, upon notice of default in the agreement by the party or parties agreeing to make
payment, the operating and registration privileges will be suspended.
Form 1210 (Revised 05-2013)
Mail to:
Driver License Bureau
Phone: (573) 751-7195
Visit dor.mo.gov/drivers/
P.O. Box 200
Fax:
(573) 526-7365
for additional information.
Jefferson City, MO 65105-0200
E-mail: dlbmail@dor.mo.gov
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