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Fillable Printable Form 5400 - County Collector And Assessor System Access Form

Fillable Printable Form 5400 - County Collector And Assessor System Access Form

Form 5400 - County Collector And Assessor System Access Form

Form 5400 - County Collector And Assessor System Access Form

Missouri Department of Revenue
County Collector and Assessor System Access Form
Form
5400
Form 5400 (Revised 06-2015)
Mail to:Motor Vehicle Bureau Phone: (573) 751-8749
Attention: Tammy Stayton Fax: (573) 751-3551
P.O. Box 703 E-mail: mvbmail@dor.mo.gov
Jefferson City, MO 65105-0703
Visit //www.dor.mo.gov/motorv/
for additional information.
County Information
Signature
CountyContact Name
AddressCity
StateZip CodeTelephone NumberSecurity Access Code
E-mail Address
Under penalties of perjury, I declare that the above information and any attached supplement is true, completed, and correct.
Signature of County OfcialTitleDate (MM/DD/YYYY)
__ __ /__ __ /__ __ __ __
(___ ___ ___) ___ ___ ___ - ___ ___ ___ ___
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