Fillable Printable Form 2510 - Application For Repossessed Placard(S)

Form 2510 - Application For Repossessed Placard(S)

Form

2510

Missouri Department of Revenue

Application for Repossessed

Placard(s)

Mail to: Motor Vehicle Bureau

Dealer Licensing Section Phone: (573) 526-3669

P.O. Box 43 Fax: (573) 751-4789

Jefferson City, MO 65105 E-mail: [email protected]

Visit http://dor.mo.gov/

for additional information.

Form 2510 (Revised 02-2014)

Applicant Information

(__ __ __)__ __ __-__ __ __ __

__ __/__ __/__ __ __ __

I hereby certify that the information given herein is correct and that the placard(s) applied for will be used in accordance with

the laws of the State of Missouri. The signature below shall certify that I have and will maintain, during the period of registration,

financial responsibility with respect to each motor vehicle that I own, license or operate on the streets or highways.

Signature of Applicant Date (MM/DD/YYYY)

Number Of Placard(s) Requested Repossessed Placard Number(s) Assigned

Business Name Telephone Number

Street Address County

City State Zip Code

Notary Information

Subscribed and sworn before me, this

day of year

State 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

__ __/__ __/__ __ __ __

Reason Required

r Lost r Stolen r Mutilated r Destroyed

Replacement Placard(s)

List repossessed placard(s) to be replaced:

Placard Number New Placard Number

Instructions To Applicant

Any false statement is a violation of the law and may be punished by fine, imprisonment or both. (Section 301.420 RSMo.)

1. Complete the application in full. Application should be typewritten or printed legibly (print firmly so that all copies are readable).

2. Fees – Fees are $50.00 for the original placard, additional placards are $10.50 each. If a placard is lost, stolen or destroyed, you may

apply for a replacement placard at $8.50 per placard. In order to obtain a replacement placard, the application must be notarized.

Submit a check or money order (do not send cash) for the correct amount made payable to the Missouri Department of Revenue.

Note: The Missouri Department of Revenue may electronically resubmit checks returned for insufficient or uncollected funds.

3. When the application is completed, return all copies to the address listed below. The placard(s) will be mailed to the applicant by the

motor vehicle bureau after the application has been approved.

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