Fillable Printable 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: [email protected]

Jefferson City, MO 65105-0703

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

for additional information.

County Information

Signature

County Contact Name

Address City

State Zip Code Telephone Number Security 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cial Title Date (MM/DD/YYYY)

__ __ /__ __ /__ __ __ __

(___ ___ ___) ___ ___ ___ - ___ ___ ___ ___

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