Form 5005 - Application/Affidavit for Missouri ...

1 $10 REPO. title $ PROCESSING FEE $5 QUICK FEE TAX EXEMPT (#13)TOTAL$ title APPLICANTANY FALSE STATEMENT IN THIS APPLICATION IS A VIOLATION OF THE LAW AND MAY BE PUNISHED BY FINE OR IMPRISONMENT OR VALIDATIONDEBTOR S title NO. STATE CURRENT MILEAGE CODE REPOSSESSION DATE OF UNITYEAR MAKE UNIT IDENTIFICATION NUMBER (IF TYPING, DISREGARD BLOCK CONSTRAINTS) BODY STYLELIENHOLDER NAME STREET ADDRESS, OR BOX NUMBER CITY, STATE, ZIP CODEMISSOURI DEPARTMENT OF REVENUEMOTOR VEHICLE BUREAUPO BOX 2076, JEFFERSON CITY MO 65105-2076(573) 526-3669 FOR MISSOURIREPOSSESSION title form 5005 (Revised 08-2019)STAPLEHEREBRAND CODEUNIT DESCRIPTIONDEBTORLOC.

2 OF UNITMAIL TO LOCATIONSIGNATUREFUEL TYPE ALL APPLICATIONS - QUESTIONS SHOULD BE REFERRED TO (573) USE ONLY-REJECT NUMBERFORM5005(REV. 08-2019)IF UNIT WAS TOWED, RECORD THE NAME OF THE LAW ENFORCEMENT AGENCY THE VEHICLE WAS REPORTED TO:TELEPHONE NUMBER( ) KIND OF VEHICLE ( ) CYLINDER HORSEPOWERREPO. title FEESDEBTOR S NAME STREET ADDRESS, , OR BOX NUMBER CITY, STATE, ZIP CODE STREET OR PHYSICAL ADDRESS OF THE UNIT LOCATION CITY, STATE, ZIP CODE MAIL title TO ADDRESS BELOW IF DIFFERENT FROM APPLICANT S ADDRESSNAMESTREET ADDRESS, , OR BOX NUMBER CITY, STATE, ZIP CODEMODEL NUMBERCOLOR LENGTH MATERIAL BOAT TYPE ENGINE DRIVE TYPE TYPE OF PROPULSIONIF Missouri title FILL IN FIRST FOUR LETTERS OF PREVIOUS OWNER S LAST NAME FT. / VESSEL LICENSE ID NUMBER TYPE OF USE MONOTARIZATION REQUIREDBOAT/VESSEL OUTBOARD MOTOR TRAILERNOTARY PUBLIC EMBOSSER STATE COUNTY (OR CITY OF ST.)

3 LOUIS) OR BLACK RUBBER STAMP SEAL SUBSCRIBED AND SWORN BEFORE ME, THIS DAY OF NOTARY PUBLIC SIGNATURE MY COMMISSION EXPIRES NOTARY PUBLIC NAME (TYPED OR PRINTED)I certify under penalties of perjury that the debtor has defaulted in payment of the debt on the unit listed above and the unit has been repossessed either by legal process or in accordance with the terms of the security contract. I have written consent from all owners and/or lienholders of record to repossess this unit or I have provided all owners/lienholders with a 10-day written notice by first class mail or as outlined in the Uniform Commercial Code, of the repossession and that an application for repossessed title will be made and the notice has now expired. If the unit being repossessed is a manufactured home, I further affirm that as the holder of such manufactured home, I have paid all rent accrued to the owner of any real property where such rent is obligated to be paid pursuant to the provisions of Section , RSMo, if OF LIENHOLDER S REPRESENTATIVE (REQUIRED)X BOAT/VESSEL/ OUTBOARD MOTOR MOTOR VEHICLE MANUFACTURED HOMEG - GAS L - LP - PROPANED - DIESEL E - ELECTRICN - NAT.

4 GAS V - PLUG-IN HYBRIDO - OTHER ELEC. VEHICLE KIND OF VEHICLE N - AUTOCYCLEP - PASSENGER M - MOTORCYCLET - TRUCK C - TRICYCLED - TRAILER/MANF. HOME R - REC. VEHICLEB - BUS A - ATV $2 NOTARY FEE A completed, signed, and notarized Application/Affidavit FOR Missouri REPOSSESSION title (DOR-5005). A title fee of $10 and a $ processing fee must be submitted. An additional $5 must also be submitted if a quick title is requested. A validated copy of the Notice of Lien (DOR-4809 or DOR-108) receipt or the actual title must accompany the repossession application reflecting the lienholder. Repossession titles cannot be issued on documented : License Office notary service - $ DOCUMENTSC heck or money order may be accepted as payment. Make the check or money order payable to: Missouri Department of Revenue. The check must be preprinted with the check writer s name and address, bank code, and account number. It must also include the following information regarding the check writer: 1.

5 Driver license or non-driver license number; 2. Date of birth; and 3. Daytime phone NOT SEND CASH WHEN APPLYING BY MAIL. THE Missouri DEPARTMENT OF REVENUE MAY ELECTRONICALLY RESUBMIT CHECKS RETURNED FOR INSUFFICIENT OR UNCOL LECTED FUNDS. Other restrictions may also METHODSTo apply for repossession title for a motor vehicle, trailer, all terrain vehicle, manufactured home, boat/vessel, or outboard motor you must submit the required documents to your local Motor Vehicle and Driver Licensing Contract Office or mail to the Missouri Department of Revenue, Motor Vehicle Bureau, Box 2076, Jefferson City, MO THIS APPLICATIONBOAT/VESSEL CODES form 5005 (Revised 08-2019)

6 TYPE OF USE Charter Fishing Commercial Fishing Commercial Passenger Carrying Dealer or Manufacturer DemonstrationOther Commercial Operation Pleasure Rent or Lease COLOR CODE Beige BGEB lack BLKBlue BLUB rown BROB ronze BRZC hrome (Stainless Steel) COMC opper CPRC ream (Ivory) CRM Dark Blue DBLDark Green DGRGold GLDG reen GRNGray GRYL avender LAVL ight Blue LBLL ight Green LGRM aroon MARO range ORGP urple PLEPink PNKRed REDS ilver (Aluminum)

7 SILTan TANT urquoise TRQW hite WHIY ellow YELTYPE OF MATERIAL CODEA luminum ALUMC oncrete CONCRF iberglass FGLAS Hypal HYPALK evla - Type of Fiberglass KEVLAO ther OTHERP lastic PLASR ubber/Vinyl/Canvas RUBBRS teel STEELWood WOODBOAT TYPE CODE Airboat AIRA mphibious AMPA uxiliary Sail AUXB arge BARBass Boat BASC abin Motorboat CABC anoe CANC ommercial COMC ruiser CRUDay Cruiser DAYDeck Boat DECDrag or Performance Boat DRGH ouseboat HSEH overcraft HOVH ydrofoil HYDH ydroplane HROI nflatable Boat RAFJet Ski JETO fficial OFFOpen Motorboat OPEO ther OTHP addlecraft PADP ersonal Watercraft PER Pontoon PON Rowboat ROWR unabout RUNSail Only SALS ubmarine SUBSurf Jet SURU tility UTLWet Bike WETY acht YATENGINE DRIVE TYPE CODEI nboard INBO

8 Utboard OUTPod Drive PODS terndrive STEO ther OTHTYPE OF PROPULSION CODEAir Thrust AIRM anual MANO ther OTHP ropeller PROSail SAILW ater Jet WAT