Fillable Printable Form 5062 - Missouri Department Of Revenue

Form 5062 - Missouri Department Of Revenue

MISSOURI DEPARTMENT OF REVENUE

MOTOR VEHICLE BUREAU

APPLICATION FOR VEHICLE/TRAILER IDENTIFICATION

NUMBER PLATE OR VERIFICATION

FORM

5062

(REV. 12-2015)

CONTROL NO.

SEE INSTRUCTIONS ON REVERSE

MOTOR VEHICLE/TRAILER/MANUFACTURED HOME

SECTION B — NOTARY PUBLIC

VALIDATION ONLY

REGISTERED OWNER (LAST, FIRST, MIDDLE) DEALER NUMBER COUNTY DAYTIME TELEPHONE NUMBER

STREET, RR, OR P.O. BOX NUMBER CITY STATE ZIP CODE

YEAR MAKE VEHICLE IDENTIFICATION NUMBER MISSOURI TITLE NUMBER LICENSE NUMBER

BODY STYLE MODEL COLOR CYLINDERS H.P. MILEAGE

COMPLETE THE INFORMATION BELOW IF APPLYING FOR A REPLACEMENT VIN — APPLICATION MUST ALSO BE NOTARIZED

LOSS OF VIN. PLATE REPORTED TO: DATE REASON REQUIRED

LOST STOLEN MUTILATED DESTROYED

I certify that the statements above are true and that I am the registered

owner of the above described unit(s). SIGNATURE

APPLICANT’S SIGNATURE

NOTARY PUBLIC EMBOSSER OR STATE COUNTY (OR CITY OF ST. LOUIS)

BLACK INK RUBBER STAMP SEAL

SUBSCRIBED AND SWORN BEFORE ME, THIS

DAY OF YEAR

USE RUBBER STAMP IN CLEAR AREA BELOW.

NOTARY PUBLIC SIGNATURE MY COMMISSION

EXPIRES

NOTARY PUBLIC NAME (TYPED OR PRINTED)

I certify that on __ __

__ __

__ __ __ __ I physically inspected the above described vehicle/trailer after the

applicant provided satisfactory proof of ownership and found the identification number(s) as recorded below.

I certify that on

__ __

__ __ __ __ I did affix the new/replacement VIN plate, control number ______________________________ issued by the

Department of Revenue to the above vehicle.

The outstanding VIN plate listed above has been surrendered and forwarded to the Missouri State Highway Patrol, Motor Vehicle Inspection Division.

PUBLIC VIN

POLICE VIN

The VIN plate listed below must be surrendered

at the time a new replacement number is issued.

_________________________________

LAW ENFORCEMENT AGENCY FILE NUMBER EXAMINING OFFICER’S SIGNATURE TELEPHONE NUMBER BADGE NO.

LAW ENFORCEMENT AGENCY LAW ENFORCEMENT OFFICER’S SIGNATURE BADGE NO.

APPLICANT COMPLETES

NOTARY COMPLETES

LAW ENFORCEMENT COMPLETES

INSTRUCTIONS:

Step 1: Applicant must complete and sign Section A.

Step 2:

If a replacement vehicle identification number (VIN) is required,

Section B must be notarized by a notary public.

Step 3:

Submit your motor vehicle/trailer and this form to authorized law

enforcement as designated on the reverse side of this form.

Step 4:

Submit the completed form to the Department of Revenue as noted

on the reverse side of this form.

PURPOSE OF INSPECTION: (Select one):

TITLE CORRECTION OR VEHICLE VIN VERIFICATION

NEW IDENTIFICATION NUMBER PLATE

REPLACEMENT IDENTIFICATION NUMBER PLATE

TRAILER WITH A SALVAGE TITLE

UNIT: (Select one):

MOTOR VEHICLE

MANUFACTURED TRAILER

HOMEMADE TRAILER (16 FEET OR MORE)

MANUFACTURED HOME BUILT PRIOR TO 1976

(REQUIRES INSPECTION FROM PUBLIC SERVICE COMMISSION)

SECTION A — APPLICANT

YEAR MAKE BODY STYLE MILEAGE CYLINDERS

REMARKS AND DISCREPANCIES NOTED

TO BE COMPLETED BY AUTHORIZED LAW ENFORCEMENT WHEN A DR NUMBER OR REPLACEMENT VIN PLATE IS AFFIXED.

REPLACEMENT VIN REQUIRED NEW VIN REQUIRED — IF A TRAILER: UNIT IS: HOMEMADE MORE THAN 16 FEET MANUFACTURED TRAILER

NO NEW/REPLACEMENT VIN REQUIRED TYPE OF TRAILER ________________________________________________ NO OF AXLES ________________ LENGTH ______________

Office Use Only — New ID:

CONDITION:

DAMAGED

RUNNING

REBUILT

MOTOR CHANGE

OTHER

____________________

SECTION C — FOR AUTHORIZED LAW ENFORCEMENT AGENCY USE ONLY — DO NOT WRITE BELOW THIS LINE

__ __ __ __ __

(

__ __ __

)

__ __ __

__ __ __ __

__ __ __ __ __

__ __

__ __ __ __

(

__ __ __

)

__ __ __

__ __ __ __

MOTOR VEHICLES AND TRAILERS ONLY. NOT TO BE USED FOR MANUFACTURED HOMES.

Form 5062 (Revised 12-2015)

VIN TO BE REPLACED

DISTRIBUTION: WHITE — DEPARTMENT OF REVENUE; CANARY — INSPECTING LAW ENFORCEMENT AGENCY

SAMPLE

Not For Use or

Distribution

INSTRUCTIONS TO APPLICANT — READ CAREFULLY

This form is to be used when a vehicle/trailer identification number (VIN) plate needs to be verified, issued, or replaced.

Any false statement in this application is a violation of the law and may be punished by fine or imprisonment or both.

1. Print or typewrite with black ink.

2. Before the application can be accepted by the Missouri Department of Revenue (department), an examination to determine the

true identity of the vehicle/trailer must be made only by the authorized law enforcement, the Missouri State Highway Patrol

(MSHP), a member of the St. Louis City or County Auto Theft Unit or the Missouri Public Service Commission (manufactured

homes only) as outlined below.

3. This application must be accompanied by the documents and fees outlined below. If the application is for a corrected title/

vehicle verification or for a new VIN plate for a homemade trailer, the application may be submitted to any Department of Revenue

contract office. If the application is for a new VIN plate for a motor vehicle or manufactured trailer, or for a replacement VIN for

any motor vehicle or trailer, the application must be mailed directly to Motor Vehicle Bureau, PO Box 2076, Jefferson City MO

65105-2076.

The original form must be submitted to the department. The copy will be retained by the inspecting agency.

DO NOT SEND CASH. Checks or money orders 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. Driver license or non-driver license number;

2. Date of birth; and

3. Daytime phone number.

THE MISSOURI DEPARTMENT OF REVENUE MAY ELECTRONICALLY RESUBMIT CHECKS RETURNED FOR INSUFFICIENT OR

UNCOLLECTED FUNDS. Other restrictions may also apply.

4. The identification number plate (excluding a new VIN plate for a homemade trailer) will be forwarded to the applicable agency

(as listed in paragraph above 2) for proper attachment to the unit. The agency will contact the owner for an appointment to attach

the plate to the unit.

WHO CAN COMPLETE THE INSPECTION PORTION OF THIS FORM?

Title Correction or Vehicle VIN Verification — Any authorized law enforcement — Missouri State Highway Patrol (MSHP), county

sheriff, police, etc. An additional inspection completed by an authorized officer of the MSHP or a member of the St. Louis City or

County Auto Theft Unit may be required. The inspection portion of this form is not required for a new or replacement VIN on a

manufactured home (complete section A and see list of required documents below).

New VIN for Trailer:

• Manufactured trailer — Any authorized officer of the MSHP or a member of the St. Louis City or County Auto Theft Unit.

• Homemade trailer 16 feet or more in length — County sheriff from applicant’s county or MSHP.

• Homemade trailer less than 16 feet in length — Do not use this form. The trailer must be inspected by an official safety inspection station

• Trailer with a Salvage Title — The form must be completed by an authorized officer of the Missouri State Highway Patrol or St. Louis

City or County Auto Theft Unit.

• Replacement VIN — Any authorized officer of the MSHP or a member of the St. Louis City or County Auto Theft Unit.

• New and Replacement VIN for Manufactured Home — Home must be manufactured prior to 1976 and can only be inspected by the

Missouri Public Service Commission.

WHAT DOCUMENTS AND FEES ARE REQUIRED?

Title Correction

• This completed form;

• Application for title;

• Certificate of title; and

• $11 (title and processing fee).

New VIN Plate for Trailer

• This completed form;

• Application for title;

• Certificate of title (unless homemade trailer over 16 feet being titled for the first time);

• $11.00 (title and processing fee);

• $10.00 (inspection fee), if applicable — not required if the county sheriff collected the fee (applies only to homemade trailers over 16 feet);

• $10.00 (VIN plate fee or replacement VIN plate fee and processing fee), if applicable; and

• State and local taxes and applicable title penalties if a change of ownership (does not apply to first time title of a homemade trailer).

Replacement VIN for any Motor Vehicle, Trailer, or Manufactured Home

• This completed form (for a new or replacement VIN on a manufactured home, the homeowner must complete section A of this form

only, sign and have their signature notarized);

• $10.00 (replacement VIN plate fee and processing fee); and

• Inspection documentation from the Missouri Public Service Commission.

If a change of ownership, the following must also be submitted:

• Properly assigned title;

• Title application;

• $11.00 (title and processing fee); and

• State and local taxes and applicable title penalties if a change of ownership.

Form 5062 (Revised 12-2015)

SAMPLE

Not For Use or

Distribution