Fillable Printable Form 237 Motor Vehicle Accident Release
Fillable Printable Form 237 Motor Vehicle Accident Release
Form 237 Motor Vehicle Accident Release
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Subscribed and sworn before me, this
day of year
State County (or City of St. Louis) My Commission Expires
Notary Public Signature
Notary Public Name (Typed or Printed)
___ ___ / ___ ___ / ___ ___ ___ ___
Form 237 (Revised 06-2013)
Missouri Department of Revenue
Motor Vehicle Accident Release
Form
237
Notary Required
Embosser or black ink rubber stamp seal
Printed Name of Person Giving Release
Signature Date (MM/DD/YYYY)
Signature
Under penalties of perjury, I declare that the above information and any attached supplement is true, complete, and correct.
Mail to: Driver License Bureau Phone: (573) 751-7195
301 West High Street - Room 470 Fax: (573) 526-7365
Jefferson City, MO 65105-0200
Visit dor.mo.gov/drivers/ for
additional information.
I, ________________________________ hereby forever release and discharge ___________________________________________,
any heirs, executors, administrators, and all firms, corporations, and persons on their behalf liable, from all claims, demands, damages,
actions, or causes of action arising from or growing out of, any and all personal injuries and property damage, now apparent as well as
those which may hereafter develop as a direct or indirect result of a collision which occurred , at or near
__________________________________________________________________________________________Missouri.
I, ___________________________________, state that I am the parent or guardian of __________________________________,
a minor under 18 years of age, and that the above release is made at my request and that I make this release for said minor child,
and that I agree to hold harmless any person against any action, claim or demand for said minor child or any other person for
injuries or damages to said minor child.
Subscribed and sworn before me, this
day of year
State County (or City of St. Louis) My Commission Expires
Notary Public Signature
Notary Public Name (Typed or Printed)
Notary Required
Embosser or black ink rubber stamp seal
___ ___ / ___ ___ / ___ ___ ___ ___
Printed Name of Person Giving Release
Signature Date (MM/DD/YYYY)
Signature
Under penalties of perjury, I declare that the above information and any attached supplement is true, complete, and correct.
Additional Release of Parent or Guardian For Injuries to Minor Child
___ ___ / ___ ___ / ___ ___ ___ ___
(MM/DD/YYYY)
Case Number
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