Fillable Printable 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 DESCRIPTION — Complete all applicable blocks.

FIRST LIEN — Complete the FIRST LIENHOLDER INFORMATION section, if applicable.

SECOND LIEN — Complete the FIRST and SECOND LIENHOLDER INFORMATION sections, if applicable.

First Lienholder Authorization — This 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 SECTION — Enter 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