Form 4012 - Historic Vehicle Log Page 2
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2MISSOURI DEPARTMENT OF REVENUE
MOTOR VEHICLE BUREAU
HISTORIC VEHICLE LOG
Section 301.131.4, RSMo (Supp. 1989) states, “The owner of the historic vehicle
shall be responsible for keeping a log of miles driven for personal use each calendar
year. Such log must be kept in the historic vehicle when the vehicle is driven on any
state road.”
OWNER’S NAME
OWNER’S ADDRESS
CITY, STATE, ZIP CODE
VEHICLE IDENTIFICATION NUMBER
YEAR
MAKE
LICENSE NUMBER
MO 860-1034 (10-2006)
DOR-4012 (10-2006)
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