Under penalties of perjury, I declare that the above information and any attached supplement is true, complete, and correct.
Signature of Owner Printed Name Date (MM/DD/YYYY)
__ __ /__ __ /__ __ __ __
Signature
Owner or joint owner of a motor vehicle, watercraft, or outboard motor may complete this application for receipt of payment only.
For a duplicate title, refer to the Application for Missouri Title and License, (Form 108). This form must be notarized.
Notary Information Required
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
__ __ /__ __ /__ __ __ __
Validation
Requesting: r Title Receipt (Showing Tax Paid) r Registration Receipt (Showing Purchase of License)
Reason: r Destroyed r Lost r Mutilated r Stolen
Mail to: Motor Vehicle Bureau Phone: (573) 526-3669
P.O. Box 2048 Fax: (573) 751-7060
Jefferson City, MO 65105-2048 E-mail: mvrecords@dor.mo.gov
Visit http://dor.mo.gov
for additional information.
Name (as it appears on card) Card Type Card Number Expiration Date
__ __ /__ __
Payment Options
The total fees for a title or registration receipt is $8.50 for each receipt made and a $6.00 processing fee.
The Missouri Department of Revenue may electronically resubmit checks returned for insufficient or uncollected funds. A convenience fee
will be charged for credit or debit card transactions.
If you are paying by credit or debit card you must provide the following:
Cash
Check
Money
Order
Debit
Card
Discover Visa
American
Express
Central Office Visit
Mail
Fax or E-Mail
Mastercard
$0.00 - $50.00 $1.25
$50.01 - $75.00 $1.75
$75.01 - $100.00 $2.15
$100.01 or more 2.15%
Total Record Fees Convenience Fee
Vehicle,
Watercraft, or
Outboard Motor
Year Make Kind of Vehicle Plate Number Expiration Year
Title Number Vehicle Identication Number (VIN), Hull Identication Number (HIN), or Outboard Motor Identication Number (OBIN)
Owner’s Legal Name Phone Number
(__ __ __) __ __ __–__ __ __ __
Address City State Zip Code
Applicant
Would you like the requested information to be sent somewhere other than to the record holder’s address listed above? r Yes r No
If yes, how would you like it to be sent?
r Mail (provide address) r Fax (add $0.50 per page faxed; provide fax number) r Email (provide email address) r Certified Record
Name Agency Name (if applicable) Fax Number
(__ __ __) __ __ __–__ __ __ __
Address City State Zip Code
Email Address
Mailing and
Fax Information
Form 2519 (Revised 08-2019)
Form
2519
Request for Receipt of Title
or Registration
Note: License Ofce notary service - $2.00
