Fillable Printable Form 5421 - Missouri Department Of Revenue

Form 5421 - Missouri Department Of Revenue

Form

5421

Missouri Department of Revenue

Insurance Company Application for

Salvage Title or Junking Certificate

Instructions to Insurers: An insurer which purchases a vehicle that is currently titled in Missouri through the claims adjustment

process for which the insurer is unable to obtain a negotiable title may make application to the Department of Revenue for a

salvage certificate of title or junking certificate.

Insurance Company Name Date of Loss (MMDDYYYY) Telephone Number

__ __/__ __/__ __ __ __ (__ __ __) __ __ __-__ __ __ __

Insurance Company Street Address City State Zip

Name of Insured

Insurance Company Information

Describe Circumstances

The vehicle is currently located at

Year Make Model Vehicle Identification Number Mileage

• The lienholder of record has been notified of our intent to obtain a salvage title or junking certificate or a lien release

from the lienholder of record is enclosed (if applicable); and

• At least two written attempts to obtain the certificate of title, transfer documents or other acceptable evidence of title from

the most recent owner of record have been made.

Under penalty of perjury, I declare the following:

• The signatory is an agent of the insurance company identified above;

• The vehicle identified on this document was obtained by the insurance company identified above under the following

circumstances:

Signature Printed Name Date (MM/DD/YYYY)

__ __/__ __/__ __ __ __

Street Address City State Zip

Applying for a r Salvage Title ($11.00) r Junking Certificate ($2.50)

Vehicle Information

Instructions

The following items must be submitted to the central office in Jefferson City (see address below) or this application will be rejected

for incompleteness:

• Fully completed application;

• Copy of proof of claim payment;

• Copies of the two written notices to the vehicle owner and evidence that such notices were sent to the owner;

Evidence of notices being sent includes the tracking documentation from an established national postal or parcel delivery

service (including, but not limited to, the US Post Office, Federal Express, United Parcel Service).

• Copy of the written notice to any lienholder of record. A notarized lien release or letter of guarantee is acceptable in lieu of a

written notice to the lienholder, and

• $11.00 fee for a salvage title (payable to the Department of Revenue; includes $8.50 title fee and $2.50 processing fee); or

• $2.50 processing fee for a junking certificate (payable to the Department of Revenue).

Mail to: Motor Vehicle Bureau

Complex Unit Phone: (573) 526-3669

P.O. Box 2076 E-mail: [email protected]

Jefferson City, MO 65105-2076

Form 5421 (Revised 04-2014)

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