Have you included: r Completed application
r Completed affidavit
r Signed work order, storage agreement, or tow agreement
r Signed certified mail notification or unclaimed returned envelope
r Titling fees and processing fees
Owner Information
Year Make Vehicle or Manufacturer’s Identification Number Amount of Repair or Storage
Titled Owner’s Name Number of Months Payment Overdue
(minimum of 45 days)
Owner’s Address
City State ZIP Code
I certify that the motor vehicle, trailer, all-terrain vehicle, manufactured home, vessel, or outboard motor listed below is in my
possession and that the owner of said unit has defaulted in payment. The total amount of repair and storage that is noted
below has not been paid as evidenced by the attached work order or storage bill. The owner and lienholder listed below were
notified of this debt by certified mail on the date noted. Copies of the notification letter(s) and the certified mail card(s) have been
submitted with this affidavit. Neither the owner nor the lienholder has paid, or made satisfactory arrangements for payment of,
storage or service towing charges within 30 days since notification of my intent to title the unit. See requirements on reverse.
__ __ __ __
All Lienholders Information
Name of Vehicle Owner’s Lienholder
Street Address
City State ZIP Code
Name of Mechanic or Garage
Street Address
City State ZIP Code
Date Owner Notified by Certified Mail (MM/DD/YYYY) Signature of Applicant
__ __ /__ __/__ __ __ __
Distribution: White — Owner of Vehicle Yellow — Department of Revenue Pink — Lienholder or Secured Party
Form 1062 (Revised 09-2019)
Notary Information
Subscribed and sworn before me, this
day of year
State County (or City of St. Louis) My Commission Expires (MM/DD/YYYY)
Notary Public Signature
Notary Public Name (Typed or Printed)
Embosser or black ink rubber stamp seal
__ __ /__ __ /__ __ __ __
Affidavit for Mechanic Lien Title
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Mechanic Lien Titles
In order to apply for a mechanic lien title for a motor vehicle, trailer, all-terrain, manufactured home, vessel, or outboard motor, you must
submit the following:
1. A completed and signed Application for Missouri Title and License (Form 108) (for motor vehicles, trailers, all-terrain vehicles and
manufactured homes), or a completed and signed Application for Missouri Boat/Vessel or Outboard Motor Title and Registration
(Form 93) (for vessels or outboard motors). For type of title, record “mechanic lien.”
2. The original or a copy of the written request for labor, services, skill, materials or storage costs signed by the owner, his agent, or
at the written request of a peace officer in lieu of the owner or owner’s agent, where such owner or agent is not available to request
storage, with the maximum amount to be charged as stated.
3. A notarized affidavit from the holder of the property certifying that the owner has defaulted on payment of labor, services, skill, or
materials and that payment is 45 days past due, or that the owner has defaulted on payment, or has failed to make satisfactory
arrangements for continued storage of the chattel for 30 days since notification by mail of intent to title.
4. A statement showing the outstanding balance for all labor, services, skills, materials or storage costs accumulated up to the date of
application for title.
5. A check for $16.00 made payable to the Missouri Department of Revenue. The Missouri Department of Revenue may electronically
resubmit checks returned for insufficient or uncollected funds.
Note: License Office notary service - $2.00
Note: All requests for mechanic lien titles will be held for the 30 day notification period as required by law.
Form 1062 (Revised 09-2019)
Mail to: Motor Vehicle Bureau Phone: (573) 526-3669
P.O. Box 2076 Fax: (573) 751-5209
Jefferson City, MO 65105-2076 E-mail: mvbmail@dor.mo.gov
Visit http://dor.mo.gov/
for additional information.