Form 5315 (Revised 08-2019)
Statement of Facts Regarding Certificate of Title. I hereby state the following: (Place initials in applicable boxes)
The following facts are known by me which affect the validity of the title to the manufactured home referenced above (attach a separate
exhibit if more space is needed). ______________________________________________________________________________
I am not aware of any facts or information that could affect the validity of the title of the manufactured home or the existence or
nonexistence of a security interest in or lien on it.
Statement of FactsLienholder
Lienholder(s) Information: (In order of priority)
Lienholder Name Address City State Zip
Lienholder Name Address City State Zip
Parties requesting written acknowledgement of conversion:
Name Address City State Zip
Name Address City State Zip
Manufacturer Name Serial Number of the Manufactured Home Home is: Purchase Date (MM/DD/YYYY)
Used __ __ /__ __ /__ __ __ __
Year Make Model Name Dimensions of the Home Purchase Price or Declared Value of the Home
Current Owner Name Address City State Zip
Previous Owner Name Address City State Zip
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
__ __ /__ __ /__ __ __ __
__ __ /__ __ /__ __ __ __
Signature Title
Printed Name Date (MM/DD/YYYY)
Under the penaltes of perjury, I hereby afrm that the information contained in this application is true and accurate.
r Title r MCO (Select the appropriate box and attach the document being surrendered)
Present this completed form to your local license ofce or mail it with the appropriate fees to:
Motor Vehicle Bureau
P.O. Box 100 Phone: (573) 526-3669
Jefferson City, MO 65105-0100 E-mail:
for additional information.
Application for Surrender of Title or Manufacturer’s Certicate of Origin (MCO)
Note: License Ofce notary service - $2.00
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