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Fillable Printable Standard Lien Waiver Form - Missouri

Fillable Printable Standard Lien Waiver Form - Missouri

Standard Lien Waiver Form - Missouri

Standard Lien Waiver Form - Missouri

YEAR MAKE VIN/HIN NUMBER
PURCHASE DATE PREVIOUS TITLE NUMBER NET PRICE (AFTER TRADE-IN)
PASSENGER TRUCK ATV TRAILER MANUFACTURED HOME RV BUS BOAT/VESSEL
OUTBOARD MOTOR (EXCLUDING TROLLING MOTOR) MOTORCYCLE TRICYCLE
MISSOURI DEPARTMENT OF REVENUE
MOTOR VEHICLE BUREAU 573-526-3669
PO BOX 3355, JEFFERSON CITY MO 65105-3355 www.dor.mo.gov/mvdl
NOTICE OF LIEN, LIEN RELEASE, OR AUTHORIZATION
TO ADD/REMOVE NAME FROM TITLE
FOR DOR USE ONLY
FOR DOR USE ONLY REJECT NUMBER
TYPE ALL APPLICATIONS. IF NOT
TYPED, ATTACH COPY OF TITLE.
OWNER
INFORMATION
UNIT
DESCRIPTION
FIRST LIENHOLDER
INFORMATION
SECOND LIENHOLDER
INFORMATION
LIEN RELEASE/NOTARY
INFORMATION
OWNER’S NAME (LAST, FIRST, MIDDLE) AS SHOWN ON TITLE APPLICATION (ONLY FIRST 50 CHARACTERS WILL PRINT ON TITLE)
STREET ADDRESS COUNTY
CITY, STATE, AND ZIP CODE DLN OR FEIN
LIENHOLDER’S NAME AS SHOWN ON TITLE APPLICATION FDIC OR LIENHOLDER ID NUMBER
STREET ADDRESS CITY, STATE, AND ZIP CODE
LIEN DATE LOAN OR UNIT NUMBER
FORM
4809
(REV. 08-2014)
NOTICE OF LIEN
(NO NOTARY REQUIRED)
LIENHOLDER’S NAME AS SHOWN ON TITLE APPLICATION FDIC OR LIENHOLDER ID NUMBER
STREET ADDRESS CITY, STATE, AND ZIP CODE
LIEN DATE SUBJECT TO FUTURE ADVANCES? LOAN OR UNIT NUMBER
YES
FIRST LIENHOLDER AUTHORIZES A SECOND LIEN BY SIGNING BELOW
LIENHOLDER’S NAME AS SHOWN ON TITLE PRINTED NAME OF LIENHOLDER’S AGENT SIGNATURE OF LIENHOLDER’S AGENT
NOTARY PUBLIC EMBOSSER OR BLACK
RUBBER STAMP SEAL
STATE COUNTY (OR CITY OF ST. LOUIS) LIEN CREATION DATE RELEASE DATE
SUBSCRIBED AND SWORN BEFORE ME, THIS MY COMMISSION EXPIRES
DAY OF
NOTARY PUBLIC SIGNATURE NOTARY PUBLIC NAME (TYPED OR PRINTED)
A $2.50 processing fee must be submitted with each Notice of Lien.
__ __ /__ __ /__ __ __ __
__ __ __ __
ANY PERSON WHO KNOWINGLY AND INTENTIONALLY SUBMITS A SEPARATE DOCUMENT
RELEASING A LIEN OF ANOTHER WITHOUT THE AUTHORITY TO DO SO SHALL BE GUILTY OF
A CLASS C FELONY. (301.640 RSMo)
__ __ /__ __ /__ __ __ __
__ __ /__ __ /__ __ __ __
LIEN RELEASE—ATTACH TO TITLE
(NOTARY REQUIRED)
THE ORIGINAL DOCUMENT MUST BE SUBMITTED. It is recommended that you retain a copy for your records.
__ __ /__ __ /__ __ __ ____ __ /__ __ /__ __ __ __
ADD/REMOVE
NAME FROM TITLE
OWNER’S NAME (LAST, FIRST, MIDDLE) AS SHOWN ON TITLE APPLICATION PRINT NAME BEING ADDED OR REMOVED
STREET ADDRESS CITY, STATE, AND ZIP CODE
COUNTY TITLE NUMBER PRINTED NAME OF LIENHOLDER’S AGENT SIGNATURE OF LIENHOLDER’S AGENT
YEAR MAKE VIN/HIN NUMBER
__ __ __ __
ADD
REMOVE
LIENHOLDER AUTHORIZATION FOR OWNERS TO ADD/REMOVE NAME FOR TITLE. (NO NOTARY REQUIRED)
DOR-4809 (08-2014)
IS THIS A CHANGE OF OWNERSHIP? YES NO
DOR-4809 (08-2014)
PLEASE PERFECT YOUR LIEN IMMEDIATELY!
IMPORTANT: Liens must be led and/or received with the Department within 30 days of the loan date
(perfected) for the lienholder to be protected from the debtor ling for bankruptcy relief.
A $2.50 processing fee must be submitted with each Notice of Lien.
OWNER INFORMATION AND UNIT DESCRIPTIONComplete all applicable blocks.
FIRST LIENComplete the FIRST LIENHOLDER INFORMATION section, if applicable.
SECOND LIENComplete the FIRST and SECOND LIENHOLDER INFORMATION sections, if applicable.
First Lienholder AuthorizationThis block must be signed by the rst lienholder when adding
a second lien.
Checks may be accepted as payment. Make checks payable to: Missouri Department of Revenue.
The check must be pre-printed with the check writer’s name, 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.
Other restrictions may apply. NOTE: The Missouri Department of Revenue may electronically
resubmit checks returned for insufcient or uncollected funds.
The lienholder will receive a receipt as proof the lien has been perfected.
Submit the completed Notice of Lien (DOR-4809) to your local license ofce or by mail to the
following address:
MOTOR VEHICLE BUREAU
301 WEST HIGH STREET
PO BOX 3355
JEFFERSON CITY MO 65105-3355
NOTICE OF LIEN
OWNER INFORMATION AND UNIT DESCRIPTION SECTIONS — Complete all applicable blocks.
FIRST AND SECOND LIENHOLDER SECTIONS — Leave blank.
LIEN RELEASE SECTIONEnter the lienholder’s name as shown on title, the date of release, printed
name of the lienholder’s agent, and signature of lienholder’s agent.
NOTARIZATION — The notary information is required to be completed to release the lien.
Note: Attach the white/original copy of this form to the corresponding Certicate of Title.
Please retain the pink copy of this Lien Release (DOR-4809) for your records.
FRAUDULENT LIEN RELEASE — ANY PERSON WHO KNOWINGLY AND INTENTIONALLY
SUBMITS A SEPARATE DOCUMENT RELEASING A LIEN OF ANOTHER WITHOUT THE
AUTHORITY TO DO SO SHALL BE GUILTY OF A CLASS C FELONY. (301.640, RSMo)
LIEN RELEASE
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