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Form 2635 - Affidavit Of Ownership

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MISSOURI DEPARTMENT OF REVENUE

FORM

MOTOR VEHICLE BUREAU

2635

AFFIDAVIT OF OWNERSHIP

(REV. 04-2011)

INSTRUCTIONS

“Any false statement in this application is a violation of the law and may be punished by fine or imprisonment or both”

1. This affidavit is to be completed only when you are making application for a duplicate certificate of title for a

motor vehicle or trailer, which was originally titled in the State of Missouri between the years of 1948 and 1969.

2. Complete this form in full.

3. Submit this form and $11.00 ($8.50 title fee; $2.50 processing fee) to any license office or mail to: MISSOURI

DEPARTMENT OF REVENUE, MOTOR VEHICLE BUREAU, PO BOX 100, JEFFERSON CITY MO 65105-0100. If you

have any questions, please call (573) 526-3669. Visit our web site at

I hereby make application for duplicate title on the motor vehicle/trailer described below. I verify that the vehicle

was last titled in the State of Missouri in my name and that the original title has been lost, stolen, mutilated,

or destroyed.

OWNER’S NAME (LAST, FIRST, MIDDLE)

TELEPHONE

(

)

STREET ADDRESS, RR OR P.O. BOX NUMBER

COUNTY

CITY

STATE

ZIP CODE

MOTOR VEHICLE/TRAILER INFORMATION

YEAR

MAKE

VEHICLE IDENTIFICATION NUMBER

MILEAGE

CYLINDER

H.P.

KIND OF VEHICLE

PREVIOUS TITLE NUMBER

PREVIOUS LICENSE NUMBER PURCHASE DATE (MO/DAY/YR)

CHECK ONE BOX ONLY:

1. The lien on the vehicle shown on the original certificate of title has been released.

The notarized lien release is attached.

2. No lien was shown on the vehicle on the original certificate of title.

3. There is a lien currently on the vehicle as shown on the attached application for title.

I HEREBY STATE ALL FACTS CONTAINED HEREIN ARE TRUE TO THE BEST

OF MY KNOWLEDGE.

OWNER’S SIGNATURE

NOTARY INFORMATION REQUIRED

STATE

SUBSCRIBED AND SWORN BEFORE ME THIS

DAY OF

NOTARY PUBLIC NAME (TYPE OR PRINT)

NOTARY PUBLIC SIGNATURE

MY COMMISSION

EXPIRES

NOTARY PUBLIC EMBOSSER SEAL

COUNTY (OR CITY OF ST. LOUIS)

USE RUBBER STAMP IN CLEAR AREA BELOW.

MO 860-1649 (04-2011)

Form 2635 - Affidavit Of Ownership

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