Notice Of Lien, Lien Release, Or Authorization To Add/remove Name From Title
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MISSOURI DEPARTMENT OF REVENUE
FOR DOR USE ONLY
REJECT NUMBER
MOTOR VEHICLE BUREAU
573-526-3669
FORM
PO BOX 3355, JEFFERSON CITY MO 65105-3355
4809
NOTICE OF LIEN, LIEN RELEASE, OR AUTHORIZATION
TYPE ALL APPLICATIONS. IF NOT
TYPED, ATTACH COPY OF TITLE.
TO ADD/REMOVE NAME FROM TITLE
(REV. 02-2012)
FOR DOR USE ONLY
NOTICE OF LIEN
(NO NOTARY REQUIRED FOR THIS SECTION)
OWNER’S NAME (LAST, FIRST, MIDDLE) AS SHOWN ON TITLE APPLICATION (ONLY FIRST 50 CHARACTERS WILL PRINT ON TITLE)
STREET ADDRESS
COUNTY
CITY, STATE, AND ZIP CODE
DLN OR FEIN
PASSENGER
TRUCK
ATV
TRAILER
MANUFACTURED HOME
RV
BUS
BOAT/VESSEL
OUTBOARD MOTOR (EXCLUDING TROLLING MOTOR)
MOTORCYCLE
TRICYCLE
YEAR
MAKE
VIN/HIN NUMBER
__ __ __ __
PURCHASE DATE
PREVIOUS TITLE NUMBER
NET PRICE (AFTER TRADE-IN)
__ __ / __ __ / __ __ __ __
LIENHOLDER’S NAME AS SHOWN ON TITLE APPLICATION
FDIC OR LIENHOLDER ID NUMBER
STREET ADDRESS
CITY, STATE, AND ZIP CODE
LIEN DATE
SUBJECT TO FUTURE ADVANCES?
LOAN OR UNIT NUMBER
__ __ / __ __ / __ __ __ __
YES
FIRST LIENHOLDER AUTHORIZES A SECOND LIEN BY SIGNING BELOW
LIENHOLDER’S NAME AS SHOWN ON TITLE APPLICATION
FDIC OR LIENHOLDER ID NUMBER
STREET ADDRESS
CITY, STATE, AND ZIP CODE
LIEN DATE
LOAN OR UNIT NUMBER
__ __ / __ __ / __ __ __ __
LIENHOLDER AUTHORIZATION FOR OWNERS TO ADD/REMOVE NAME FOR TITLE.
(NO NOTARY REQUIRED FOR THIS SECTION)
OWNER’S NAME (LAST, FIRST, MIDDLE) AS SHOWN ON TITLE APPLICATION
PRINT NAME BEING ADDED OR REMOVED
ADD
REMOVE
STREET ADDRESS
CITY, STATE, AND ZIP CODE
COUNTY
TITLE NUMBER
PRINTED NAME OF LIENHOLDER’S AGENT
SIGNATURE OF LIENHOLDER’S AGENT
YEAR
MAKE
VIN/HIN NUMBER
__ __ __ __
ANY PERSON WHO KNOWINGLY AND INTENTIONALLY SUBMITS A SEPARATE DOCUMENT
LIEN RELEASE—ATTACH TO TITLE
RELEASING A LIEN OF ANOTHER WITHOUT THE AUTHORITY TO DO SO SHALL BE GUILTY OF
(NOTARY REQUIRED IF COMPLETING THIS SECTION)
A CLASS C FELONY. (301.640 RSMo)
LIENHOLDER’S NAME AS SHOWN ON TITLE
PRINTED NAME OF LIENHOLDER’S AGENT
SIGNATURE OF LIENHOLDER’S AGENT
STATE
COUNTY (OR CITY OF ST. LOUIS)
LIEN CREATION DATE
RELEASE DATE
NOTARY PUBLIC EMBOSSER OR BLACK
RUBBER STAMP SEAL
__ __ / __ __ / __ __ __ __
__ __ / __ __ / __ __ __ __
SUBSCRIBED AND SWORN BEFORE ME, THIS
MY COMMISSION EXPIRES
DAY OF
NOTARY PUBLIC SIGNATURE
NOTARY PUBLIC NAME (TYPED OR PRINTED)
A $2.50 processing fee must be submitted with each Notice of Lien.
THE ORIGINAL DOCUMENT MUST BE SUBMITTED. It is recommended that you retain a copy for your records.
DOR-4809 (02-2012)
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