Fillable Form 1398 - Statement Of Non-Litigation printable pdf download

Form 1398 - Statement Of Non-Litigation

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Missouri Department of Revenue

Form

1398

Statement of Non-Litigation

Case Number

I, _____________________________________________________________ , do hereby state that I was involved in a motor vehicle

accident on __ __ / __ __ / __ __ __ __ , as a vehicle operator or owner, that one year has elapsed since the accident, and I have not

(MM/DD/YYYY)

been served with any papers naming me as a defendant in any action of law because of injuries or damages resulting from this

accident. The other parties involved were _________________________________________________________________________

__________________________________________________________________________________________________________

Under penalties of perjury, I declare that the above information and any attached supplement is true, complete, and correct.

Signature

Driver License Number

Date (MM/DD/YYYY)

___ ___ / ___ ___ / ___ ___ ___ ___

Address

City

State

Zip Code

Form 1398 (Revised 05-2013)

Mail to:

Driver License Bureau

Phone: (573) 751-7195

Visit dor.mo.gov/drivers/

301 West High Street, Room 470

Fax:

(573) 526- 7365

for additional information.

P.O. Box 200

E-mail: dlbmail@dor.mo.gov

Jefferson City, MO 65105-0200

Form 1398 - Statement Of Non-Litigation

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