Transcription of Form 2519 - Request for Receipt of Title or Registration
1 Under penalties of perjury, I declare that the above information and any attached supplement is true, complete, and of Owner Printed Name Date (MM/DD/YYYY) __ __ /__ __ /__ __ __ __SignatureOwner or joint owner of a motor vehicle, watercraft, or outboard motor may complete this application for Receipt of payment only. For a duplicate Title , refer to the Application for Missouri Title and License, (Form 108). This form must be Information RequiredSubscribed and sworn before me, this day of yearState County (or City of St. Louis) My Commission Expires (MM/DD/YYYY)Notary Public Signature Notary Public Name (Typed or Printed) Embosser or black ink rubber stamp seal__ __ /__ __ /__ __ __ __ValidationRequesting: r Title Receipt (Showing Tax Paid) r Registration Receipt (Showing Purchase of License)Reason: r Destroyed r Lost r Mutilated r StolenMail to: Motor Vehicle Bureau Phone: (573) 526-3669 Box 2048 Fax: (573) 751-7060 Jefferson City, MO 65105-2048 E- mail : Visit additional (as it appears on card) Card Type Card Number Expiration Date__ __ /__ __Payment OptionsThe total fees for a Title or Registration Receipt is $ for each Receipt made and a $ processing fee.
2 The Missouri Department of Revenue may electronically resubmit checks returned for insufficient or uncollected funds. A convenience fee of + $ will be charged for each credit or debit card you are paying by credit or debit card you must provide the following:Vehicle,Watercraft, orOutboard MotorYear Make Kind of Vehicle Plate Number Expiration YearTitle Number Vehicle Identification Number (VIN), Hull Identification Number (HIN), or Outboard Motor Identification Number (OBIN)Owner s Legal Name Phone Number (__ __ __) __ __ __ __ __ __ __Address City State Zip CodeApplicantWould you like the requested information to be sent somewhere other than to the record holder s address listed above? r Yes r NoIf yes, how would you like it to be sent? r mail (provide address) r Fax (add $ per page faxed; provide fax number) r Email (provide email address) r Certified RecordName Agency Name (if applicable) Fax Number (__ __ __) __ __ __ __ __ __ __Address City State Zip CodeEmail AddressMailing and Fax InformationCashCheckMoney OrderDebit CardDiscoverVisaAmerican ExpressCentral Office VisitMailFax or E-MailMastercardForm 2519 (Revised 09-2022)Form2519 Request for Receipt of Title or RegistrationNote: License Office notary service - $
