Form 5046 Sample - 40 Year Or Older Reconstructed Motor Vehicle Valued At 3,000 Dollars And Below Affidavit Of Ownership And Inspection
ADVERTISEMENT
1
2MISSOURI DEPARTMENT OF REVENUE
MOTOR VEHICLE BUREAU
PO BOX 3325, JEFFERSON CITY MO 65105-3325
(573) 526-3669
FORM
5046
40 YEAR OR OLDER RECONSTRUCTED MOTOR VEHICLE VALUED AT
$3,000 AND BELOW AFFIDAVIT OF OWNERSHIP AND INSPECTION
(REV. 9-2004)
APPLICANT
VALIDATION ONLY
APPLICANT’S NAME (VEHICLE OWNER)
ADDRESS
CITY
STATE
ZIP CODE
TELEPHONE NUMBER
(
)
YEAR
MAKE
MODEL
VEHICLE IDENTIFICATION NUMBER
THE VEHICLE ABOVE WAS OBTAINED BY THE FOLLOWING MEANS
MOTOR VEHICLE - CHECK AT LEAST TWO MAJOR COMPONENT PARTS THAT WERE REPLACED
COWL
REAR CLIP
FRAME
BODY
CAB
FRONT CLIP
FRONT END ASSEMBLY
MOTORCYCLE - CHECK AT LEAST TWO MAJOR COMPONENT PARTS THAT WERE REPLACED
FRAME
ENGINE
TRANSMISSION
I certify that the facts above are true and that I have reconstructed the vehicle by replacing two or more major component parts as checked above and the
fair market value of the vehicle after reconstruction is $3,000 or less.
SIGNATURE OF OWNER
®
NOTARY INFORMATION
AFFIX SEAL IN THIS BOX
SWORN TO AND SUBSCRIBED BEFORE ME THIS
DAY OF
MY COMMISSION EXPIRES
NOTARY PUBLIC SIGNATURE
TO BE COMPLETED BY A MEMBER OF ANY LAW ENFORCEMENT AGENCY
1. COLOR
2. YEAR
3. PUBLIC VIN
YEAR
4. MAKE
5. CYL.
6. POLICE VIN
YEAR
7. MODEL
8. H.P.
9. ENGINE VIN
YEAR
10. BODY STYLE
11. GVWR
12. TRANSMISSION VIN
YEAR
13. MILEAGE
14. FEDERAL LABEL
15. CHECK WHICH OF THE FOLLOWING PARTS WERE CHANGED
COWL
REAR CLIP
FRAME
BODY
CAB
FRONT CLIP
FRONT-END ASSEMBLY
MOTOR/ENGINE
TRANSMISSION
16. REMARKS OR ANY DISCREPANCIES NOTED (USE ADDITIONAL SHEET OF PAPER IF NECESSARY)
17.
VERIFIED VEHICLE BEING RECONSTRUCTED
18. RECOMMENDED DOR ISSUE:
REPLACEMENT VIN
DR#
19. I CERTIFY TO THE BEST OF MY KNOWLEDGE THAT MY PHYSICAL INSPECTION OF THIS VEHICLE ON ______________________________,
YEAR ________, DISCLOSED THE INFORMATION IN ITEMS 1 THRU 18 AND THAT NO PERTINENT SERIAL NUMBERED PARTS OR VEHICLE
IDENTIFICATION NUMBERS CAME FROM OR BELONG TO STOLEN VEHICLES.
20. LAW ENFORCEMENT AGENCY
21. FILE NUMBER
22. EXAMINING OFFICER’S SIGNATURE
23. EXAMINING OFFICER’S PHONE NUMBER
24. BADGE NUMBER
DISTRIBUTION:
WHITE - APPLICANT SUBMIT TO REVENUE
CANARY - EXAMINING OFFICER
MO 860-3030 (9-04)
PINK - CUSTOMER
GOLDENROD - OFFICE AUDIT COPY
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form Au-477 - Aircraft Owner Or Operator Declaration Motor Vehicle Fuels Tax Exemption Form - State Of Connecticut - Department Of Revenue Services
Financial
Form 78-013-10 - Affidavit Of Ownership Of Motor Vehicle For Which Application For Title Under Bond Or Cash Is Made
Legal
Affidavit Of Consent Of Infant Of The Age Of Fourteen (14) Years Or Older - New York Supreme Court
Legal
Related Categories
Parent category: Financial