General Affidavit Form - Missouri Department of Revenue

Form 768 (Revised 07-2013)
FORM
768
Missouri Department of Revenue
General Affidavit
Mail to: Motor Vehicle Bureau
P.O. Box 100 Phone: (573) 526-3669
Jefferson City, MO 65105-0100 E-mail: [email protected]
Visit 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 official 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
DOR-93 required): __________________________________________________________________________________
__________________________________________________________________________________________________
r
I certify that I am seventy-five years old or older and am no longer required to present a physician’s statement at the time
of renewal for disabled person placards or license plates.
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
__ __ /__ __ /__ __ __ __
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General Affidavit Form - Missouri Department of Revenue PDF

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