Fillable Form 5091: Request for Motor Vehicle Records with (Missouri)

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Form 5091: Request for Motor Vehicle Records with (Missouri)

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The Form 5091: Request for Motor Vehicle Records with (Missouri) form is 2 pages long and contains:

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Instructions: This form must be fully completed and approved before a requester may obtain access to restricted information. Incomplete
forms will be returned for more information. Appropriate documentation must be submitted with this form to verify your eligibility to
receive information under the provisions of federal Driver’s Privacy Protection Act (DPPA) and Missouri law, including but not
limited to, business license, insurance license, bar card, or other personal or professional credentials.
Form 5091 (Revised 08-2019)
Notary 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
__ __/__ __/__ __ __ __
Requester hereby certifies to the Missouri Department of Revenue (Department) that this request for Missouri motor vehicle records information is
made under the provisions of the Federal Driver’s Privacy Protection Act (DPPA) and Section 32.091, RSMo. Please review and carefully select
all boxes that apply to requester to obtain personal information on a restricted record. Requester is seeking information:
r (01) As a government agency (federal, state, or local) or on behalf of a government agency, in carrying out its government functions.
r (02) As a court (federal, state, or local) or on behalf of a court, in carrying out its court functions.
r (03) As a law enforcement agency (federal, state, or local) or on behalf of a law enforcement agency, in carrying out its law enforcement functions.
r (04) For use in connection with matters of motor vehicle or driver safety and theft; motor vehicle emissions, motor vehicle product alterations, recalls, or
advisories; performance monitoring of motor vehicles, motor vehicle parts and dealers; motor vehicle market research activities, including
survey research; and removal of non-owner records from the original owner records of motor vehicle manufacturers.
r (05) For use as a legitimate business only (a) to verify the accuracy of personal information submitted by an individual to the business or its agents,
employees, or contractors and (b) if such information is not correct, to obtain the correct information, but only for the purposes of preventing
fraud by pursuing legal remedies, or recovering on a debt or security interest, against the individual. (For individual requests only.)
r (06) For use in connection with any civil, criminal, administrative, or arbitral proceeding in any federal, state, or local court or agency or before any
self-regulatory body, including the service of process, investigation in anticipation of litigation, abandoned property, and the
execution or enforcement of judgments and orders, or pursuant to an order of a federal, state, or local court.
r (07) For use in research activities, and producing statistical reports, so long as the personal information is not published, redisclosed, or used to
contact individuals.
r (08) As an insurer, insurance support organization, or self-insured entity for use in connection with claims investigation activities, antifraud activities,
rating or underwriting.
r (09) For use in providing notice to the owners of towed or impounded vehicles. (Tow and impound companies only.)
r (10) For use by a licensed private investigative agency or licensed security service for a purpose permitted herein.
r (11) For use as an employer, its agent, or insurer in obtaining or verifying motor vehicle and driver record information relating to a holder of a
commercial driver’s license (CDL).
r (12) For use in the operation of a private toll transportation facility.
r (13) To disseminate to the public in a newspaper, book, magazine, broadcast, or similar form of public communication, when such dissemination
is related to the operation of a motor vehicle or to public safety.
Section B - Authorization
Requester certifies under penalty of perjury that: 1) all information on this application has been read and understood; 2) all information completed on
this application is true and correct; and 3) the willful and unauthorized disclosure of information obtained from any Department record may result in
penalties imposed under Title 18 U.S.C. Section 2724.
Requester understands that Section 302.170.7, RSMo, prohibits the sale of data derived from a person’s driver’s license application for commercial
purposes, which includes purposes motivated primarily by financial gain such as, but not limited to, surveys, marketing or solicitations, without the express
consent of the person to whom such information pertains. Requester shall not sell personal information for commercial purposes without such consent.
Signature(s) of Individual, Partner, Authorized Member or Corporate Officer, News Agent, or Government Agent
Printed Name(s)
Title of Corporate Officer, News Agent, or Government Agent
Signature
Name of Entity or Organization Telephone Number Ext.
(__ __ __)__ __ __–__ __ __ __
Requester Name Fax Number
Address City State ZIP Code
Mailing Address (If Different) City State ZIP Code
Describe the Primary Function of your Entity or Business
Describe in Detail How The Information Will Be Used
Select r Individual r Partnership r News Media
One:
r Corporation r Government Agent r LLC
Section A - Requester
(__ __ __)__ __ __–__ __ __ __
Form
5091
Request for Motor Vehicle Records with Personal Information
Note: License Ofce notary service - $2.00
Reset Form
Print Form
Form 5091 (Revised 08-2019)
Mail to: Motor Vehicle Bureau
Harry S Truman Bldg, Room 370 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.
Vehicle Owner’s Name — Last, First, Middle Initial
Vehicle Owner’s Street Address City State ZIP Code
Select Information Type (Records May Be Certified):
r Current Owner or lienholder - Requester will receive only the name and address of the latest owner and lienholder when applicable on file.
r Title History - Requester will receive a list that shows each time the ownership changed in this state, including the names and addresses of
the owners.
r Mileage History - Requester will receive a list that shows each time the ownership changed in this state, including the mileage, title numbers,
and issue dates.
r Name Search - Requester will receive a list of the current vehicles only registered in the owner’s name.
r Other (Requires Motor Vehicle Approval) - _________________________________________________________________________________
Section C - Request to Obtain Vehicle Information
Motor Vehicle
1
2
Year Make Title Number
Year Make Title Number
Vehicle Identification Number
License Plate Number Expiration Year
Vehicle Identification Number
License Plate Number Expiration Year
1
2
Year Make Title Number
Year Make Title Number
Identification Number Expiration Year
Decal Number MO Number
Identification Number Expiration Year
Decal Number MO Number
Marine
Name (as it appears on card) Card Type Card Number Expiration Date
__ __ / __ __
Requester’s Signature Printed Name
Payment Options
Please send the above record(s) by: r Mail r Fax (Add $0.50 per page faxed) r Email _______________________________________
r Select if Certified Record Requested
Records can be submitted by walk-in, mail-in, or e-mail request. The fee is $2.82 per record. 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:
The Missouri Department of Revenue may electronically resubmit checks returned for insufficient or uncollected funds.
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
__ __ __ __
__ __ __ __
__ __ __ __
__ __ __ __
__ __ __ __
__ __ __ __ __ __ __ __
__ __ __ __
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Form 5091: Request for Motor Vehicle Records with (Missouri)

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Completed 9 September 2021

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