Fillable Printable Form 5314 - Application For Confirmation Of Conversion

Form 5314 - Application For Confirmation Of Conversion

Form 5314 (Revised 08-2014)

Form

5314

Missouri Department of Revenue

Application for Conrmation of Conversion

Statement of Facts Regarding Certificate of Title. I hereby state the following: (Place initials in applicable boxes)

The following facts are known by me which affect the validity of the title to the manufactured home referenced above (attach a separate

exhibit if more space is needed). ______________________________________________________________________________

I am not aware of any facts or information that could affect the validity of the title of the manufactured home or the existence or

nonexistence of a security interest in or lien on it.

Statement

of Facts

Lienholder

Lienholder(s) Information: (In order of priority)

Lienholder Name Address City State Zip

Written

Acknowledgement

Parties requesting written acknowledgement of conversion:

Name Address City State Zip

Manufactured

Home

Manufacturer Name Serial Number of the Manufactured Home Home is: Purchase Date (MM/DD/YYYY)

New

Used __ __ /__ __ /__ __ __ __

Year Make Model Name Dimensions of the Home Purchase Price or Declared Value of the Home

Current Owner Name Address City State Zip

Previous Owner Name Address City State Zip

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

__ __ /__ __ /__ __ __ __

Signature

__ __ /__ __ /__ __ __ __

Signature Title

Printed Name Date (MM/DD/YYYY)

Under the penaltes of perjury, I hereby afrm that the information contained in this application and any exhibit which may be attached to this

document is true and accurate.

To be completed by an attorney-at-law or agent of a title insurance company.

I certify that the manufactured home described in this Application for Confirmation of Conversion is free and clear of, or has been released

from, all recorded security interests, liens, and encumbrances. Place your initials in one of the applicable boxes below:

I certify 1) that the following facts are known by me which affect the validity of the title to the manufactured home described in this

application, or 2) that I am aware of the exsistence of the following lien or encumbrance to the manufactured home described in this

application (attach a separate exhibit if more space is more space is needed). ___________________________________________

I am not aware of any facts or information which may affect the validity of the title of the certicate of title to, or the existence of any lien

or encumbrance on the manufactured home described in this application. _______________________________________________

Bar Number if an Attorney _______________________ License Number if a Title Insurance Agent _______________________

Signature of Attorney or Title Insurance Agent Typed or Printed Name Date (MM/DD/YYYY)

__ __ /__ __ /__ __ __ __

To be completed by an attorney-at-law

or agent of a title insurance company

Present this completed form to your local license ofce or mail it with the appropriate fees to:

Motor Vehicle Bureau

P.O. Box 100 Phone: (573) 526-3669

Jefferson City, MO 65105-0100 E-mail: [email protected]

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

for additional information.

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