Form 768 (Revised 08-2019)
Mail to: Motor Vehicle Bureau Phone: (573) 526-3669
P.O. Box 100 E-mail: mvbmail@dor.mo.gov
Jefferson City, MO 65105-0100
Visit http://dor.mo.gov/motorv/
for additional information.
Certification
r The motor vehicle described on the attached application has not been operated on public roads or the highways of Missouri by
myself, or my agent during the period of __ __ /__ __ /__ __ __ __ to __ __ /__ __ /__ __ __ __. (*Notarization required)
r I am giving this motor vehicle to ____________________________________________________ and there is no money or other
valuable consideration involved in the transaction.
r The vehicle described below has not been in the state of Missouri for the 60 day period immediately preceding the date of this
application for registration and will be submitted for inspection at an ofcial inspection station within 10 days after entering the state
by myself, or my agent.
r The vehicle described below was abandoned on real estate owned or purchased by me located at (address, city, state):________
__________________________________________________________________________________________________________
and has an approximate retail and or fair market value of $ __________________. Describe circumstances by which the real property
owner came into possession of the abandoned vehicle: _________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
r I certify under penalties of perjury that I have written consent from all owners and or lien holders of record to repossess boat or
vessel, or outboard motor, or I have provided all owners and lienholders with a 10-day written notice by first class mail or as outlined
in the Uniform Commercial Code, of the repossession and that an application for repossessed title will be made and the notice
has now expired. Debtor’s name and location or address of repossessed unit (*Notarization and Form 93 required):
___________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
r IcertifythatI amseventy-ve years old or older and am no longer required to present a physician’s statementat thetime ofrenewal
for disabled person placards or license plates.
r Fireghter Plates - I certify and afrm that I am a director of a re protection district, or are compensated, partially compensated,
or a volunteer member of a re department, re protection district, or voluntary re protection association in Missouri. I further afrm
that if I resign, are removed, or otherwise terminate my association with the re department, I will return my special license plates
to the Missouri Department of Revenue within 15 days. (*Notarization required)
Name of Fire District ____________________________________________________________________________________
r Other _______________________________________________________________________________________________________
____________________________________________________________________________________________________________
Any false statement in this affidavit is a violation of law, and may be punished by fine, imprisonment, or both.
Owner Year Make Model
Vehicle Identification Number Original Title Number Current License Number
Signature of Owner Date (MM/DD/YYYY)
__ __ /__ __ /__ __ __ __
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
768
General Affidavit
*License Ofce notary service - $2.00
