Fillable Printable Form 4054 - Power Of Attorney

Form 4054 - Power Of Attorney

Owner’s Printed Name

Owner’s Signature* Date (MM/DD/YYYY)

Owner’s Printed Name

Owner’s Signature* Date (MM/DD/YYYY)

Owner’s Printed Name

Owner’s Signature* Date (MM/DD/YYYY)

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)

Form

4054

Missouri Department of Revenue

Power of Attorney

Form 4054 (Revised 08-2015)

I (we) hereby appoint, __________________________________________________ as my (our) attorney-in-fact for the

purpose of:

r Transferring ownership for the following described unit:

r Making application for title for the following described unit:

r Making application for registration for the following described unit:

Motor Vehicle Bureau Phone: (573) 526-3669

P.O. Box 100 E-mail: [email protected]

Jefferson City, MO 65105-0100

Visit http://dor.mo.gov/motorv/

for additional information.

Signature

Notary Information

Embosser or black ink rubber stamp seal*

__ __ /__ __ /__ __ __ __

* Owner(s) electronic signature is permissible ONLY when assigning power of attorney to an insurance company due to

total loss. Notarization is not required if signing electronically.

with the full authority to sign on my (our) behalf all papers and documents and to do all that is necessary to this appointment.

(If insurance company involving total loss, complete boxes immediately below.)

Insurance Company Name Date of Total Loss

__ __ /__ __ /__ __ __ __

Year (YYYY) Make Identication Number

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