Standard Lien Waiver Form - Missouri

YEAR MAKE VIN/HIN NUMBER
PURCHASE DATE PREVIOUS TITLE NUMBER NET PRICE (AFTER TRADE-IN)
PASSENGER TRUCK ATV TRAILER MANUFACTURED HOME RV BUS BOAT/VESSEL
OUTBOARD MOTOR (EXCLUDING TROLLING MOTOR) MOTORCYCLE TRICYCLE
MISSOURI DEPARTMENT OF REVENUE
MOTOR VEHICLE BUREAU 573-526-3669
PO BOX 3355, JEFFERSON CITY MO 65105-3355 www.dor.mo.gov/mvdl
NOTICE OF LIEN, LIEN RELEASE, OR AUTHORIZATION
TO ADD/REMOVE NAME FROM TITLE
FOR DOR USE ONLY
FOR DOR USE ONLY REJECT NUMBER
TYPE ALL APPLICATIONS. IF NOT
TYPED, ATTACH COPY OF TITLE.
OWNER
INFORMATION
UNIT
DESCRIPTION
FIRST LIENHOLDER
INFORMATION
SECOND LIENHOLDER
INFORMATION
LIEN RELEASE/NOTARY
INFORMATION
OWNER’S NAME (LAST, FIRST, MIDDLE) AS SHOWN ON TITLE APPLICATION (ONLY FIRST 50 CHARACTERS WILL PRINT ON TITLE)
STREET ADDRESS COUNTY
CITY, STATE, AND ZIP CODE DLN OR FEIN
LIENHOLDER’S NAME AS SHOWN ON TITLE APPLICATION FDIC OR LIENHOLDER ID NUMBER
STREET ADDRESS CITY, STATE, AND ZIP CODE
LIEN DATE LOAN OR UNIT NUMBER
FORM
4809
(REV. 08-2014)
NOTICE OF LIEN
(NO NOTARY REQUIRED)
LIENHOLDER’S NAME AS SHOWN ON TITLE APPLICATION FDIC OR LIENHOLDER ID NUMBER
STREET ADDRESS CITY, STATE, AND ZIP CODE
LIEN DATE SUBJECT TO FUTURE ADVANCES? LOAN OR UNIT NUMBER
YES
FIRST LIENHOLDER AUTHORIZES A SECOND LIEN BY SIGNING BELOW
LIENHOLDER’S NAME AS SHOWN ON TITLE PRINTED NAME OF LIENHOLDER’S AGENT SIGNATURE OF LIENHOLDER’S AGENT
NOTARY PUBLIC EMBOSSER OR BLACK
RUBBER STAMP SEAL
STATE COUNTY (OR CITY OF ST. LOUIS) LIEN CREATION DATE RELEASE DATE
SUBSCRIBED AND SWORN BEFORE ME, THIS MY COMMISSION EXPIRES
DAY OF
NOTARY PUBLIC SIGNATURE NOTARY PUBLIC NAME (TYPED OR PRINTED)
A $2.50 processing fee must be submitted with each Notice of Lien.
__ __ /__ __ /__ __ __ __
__ __ __ __
ANY PERSON WHO KNOWINGLY AND INTENTIONALLY SUBMITS A SEPARATE DOCUMENT
RELEASING A LIEN OF ANOTHER WITHOUT THE AUTHORITY TO DO SO SHALL BE GUILTY OF
A CLASS C FELONY. (301.640 RSMo)
__ __ /__ __ /__ __ __ __
__ __ /__ __ /__ __ __ __
LIEN RELEASE—ATTACH TO TITLE
(NOTARY REQUIRED)
THE ORIGINAL DOCUMENT MUST BE SUBMITTED. It is recommended that you retain a copy for your records.
__ __ /__ __ /__ __ __ __ __ __ /__ __ /__ __ __ __
ADD/REMOVE
NAME FROM TITLE
OWNER’S NAME (LAST, FIRST, MIDDLE) AS SHOWN ON TITLE APPLICATION PRINT NAME BEING ADDED OR REMOVED
STREET ADDRESS CITY, STATE, AND ZIP CODE
COUNTY TITLE NUMBER PRINTED NAME OF LIENHOLDER’S AGENT SIGNATURE OF LIENHOLDER’S AGENT
YEAR MAKE VIN/HIN NUMBER
__ __ __ __
ADD
REMOVE
LIENHOLDER AUTHORIZATION FOR OWNERS TO ADD/REMOVE NAME FOR TITLE. (NO NOTARY REQUIRED)
DOR-4809 (08-2014)
IS THIS A CHANGE OF OWNERSHIP? YES NO
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