First Name Middle Initial Last Name
Business or Owner Name(s) displayed on requested title record Daytime Telephone Number
(___ ___ ___) ___ ___ ___–___ ___ ___ ___
Mailing Address City State ZIP Code
Record Holder’s
Information
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
___ ___ /___ ___ /___ ___ ___ ___
Form 5499 (Revised 08-2019)
Mail to: Motor Vehicle Bureau, Record Center 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://www.dor.mo.gov/
for additional information.
Complete this form to request a copy of your title or registration record information.
Year Make Kind of Vehicle Plate Number Expiration Year
Title Number Vehicle Identification Number (VIN), Hull Identification Number (HIN), or Outboard Motor Identification Number (OBIN)
I am requesting the following information
r Last title record issued to me for requested VIN/HIN/OBIN r All title records issued to me for requested VIN/HIN/OBIN
r Last registration record issued to me for requested VIN/HIN/OBIN r All registration records issued to me for requested VIN/HIN/OBIN
r Other (specify below)
Requested Record
Mailing & Fax
Information
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 E-mail (provide e-mail address) r Certified Record
Name Agency Name (if applicable) Fax Number
(___ ___ ___) ___ ___ ___–___ ___ ___ ___
Address City State ZIP Code
E-mail Address
Record Holder’s Signature Printed Name Date (MM/DD/YYYY)
___ ___ /___ ___ /___ ___ ___ ___
Under penalties of perjury, I declare that the above information and any attached supplement is true, complete, and correct. I authorize the
Department of Revenue to send the requested record where I designated above.
Payment Options and Signature
Name (as it appears on card) Card Type Card Number Expiration Date
__ __ /__ __
Records can be obtained 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. The Missouri Department of Revenue may electronically resubmit checks returned for insufficient or uncollected funds. You may visit
us at Central Office, Harry S Truman Building, Room 370, 301 West High Street, Jefferson City, Missouri.
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
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Form
5499
Request From Motor Vehicle Record Holder
Note: License Ofce notary service - $2.00
