Fillable Printable Form 4715 - Motor Carrier'S Insurance Self-Certification

Form 4715 - Motor Carrier'S Insurance Self-Certification

Certification

Vehicle Owner’s Name

Street Address City State Zip Code

Owner

I certify that I have insured all of my vehicles according to the

requirements of the Division of Motor Carrier and Railroad Safety

pursuant to Section 390.126, RSMo., and that such insurance is in full

force and effect.

Under penalties of perjury, I declare that the above information and any attached supplement is true, complete, and correct.

Vehicle Owner’s Signature Date (MM/DD/YYYY)

__ __/__ __/__ __ __ __

Signature

Form

4715

Missouri Department of Revenue

Motor Carrier’s Insurance Self-Certification

Visit //dor.mo.gov/

for additional information.

Form 4715 (Revised 04-2014)

This form must be attached to your motor vehicle registration application.

Motor Vehicle Bureau Phone:

301 West High Street (573) 526-3669

Jefferson City, MO 65101

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