Form 184 - Application For Motor Vehicle License
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1
2MISSOURI DEPARTMENT OF REVENUE
MOTOR VEHICLE BUREAU
FORM
EXP. MO
EXP. YR.
LICENSE PLATE OR ATV
TAB NO.
APPLICATION FOR MOTOR
DECAL NO.
184
VEHICLE LICENSE
___ ___
___ ___
REV. 08-2010
J
K
M
L
S
Z
X
V
TYPE OF
NEW OR
RENEWAL
TRANSFER
CHANGE
REPLACED (NOTARY)
SPECIAL
DATA
REINSTATEMENT
REGISTRATION
RENEW & TRANSFER
WT/ZONE
(OUT OF STOCK ONLY)
CORRECTION
(CHECK ONE BOX ONLY)
OWNER’S NAME — LAST, FIRST, MIDDLE
OFFICE VALIDATION
STREET, RR, OR PO BOX NUMBER
CITY
STATE
ZIP CODE
MO
__ __ __ __ __
REGISTRATION PERIOD
COUNTY
TELEPHONE
(__ __ __) __ __ __-__ __ __ __
1-YEAR
2-YEAR
YEAR
MAKE
VEHICLE IDENTIFICATION NUMBER (VIN)
TITLE NUMBER
___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
BODY STYLE
FUEL
KIND OF VEHICLE (KOV)
KOV
ODOMETER READING PURCHASE DATE
PASSENGER
TRUCK & BUS
P—PASSENGER
M—MOTORCYCLE
FROM INSPECTION
T—TRUCK
C—TRICYCLE
H.P.
ZONE
GR. WT/SEAT
D—TRAILER
R—REC. VEHICLE
__ __ /__ __ /__ __ __ __
B—BUS
A—ATV
EXPIRED (SAME PLATE RENEWAL) / REPLACED FROM STOCK ONLY / SURRENDERED / TRANSFERRED LICENSE PLATE
LICENSE FEE
$
LICENSE PLATE NO.
CURRENT TAB #
EXP. MO.
EXP. YR
ZONE
GR. WT/SEAT
HP
RESERVATION FEE
$
ADD H.P. FEE
$
REASON FOR REPLACEMENT — NOTARY REQUIRED
LOST
STOLEN
MUTILATED
DESTROYED
NEVER RECEIVED
TRANSFER FEE
$
LICENSE TRANSFER INFORMATION
YEAR
MAKE
VEHICLE IDENTIFICATION NUMBER
TITLE NUMBER
H.P.
FAIL TO TRANS./RENEW
$
__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
REPLACEMENT FEES
$
VEHICLE OUT OF STATE—vehicle described above has not been within the state of Missouri for the sixty (60) day period
RENEWAL PENALTY
$
immediately preceding the date of this application for registration, but will be submitted for inspection at an official safety
inspection station within ten (10) days after entering the state by me or my agent. (Notary not required)
REINSTATEMENT FEE
$
NON-USE...the motor vehicle described above has not been operated on public roads or the highways of Missouri by me
$
$1 BLIND
$ 1 ORGAN
or my agent during the period of ______________________________ to ______________________________.
FUND
FUND
(Notary required)
$10 WWII MEM. FUND
SUBTOTAL
$
I HEREBY CERTIFY THAT THE STATEMENTS HEREIN ARE TRUE TO THE BEST OF MY KNOWLEDGE. I ALSO CERTIFY THAT I HAVE AND WILL
MAINTAIN, DURING THE PERIOD OF REGISTRATION, FINANCIAL RESPONSIBILITY WITH RESPECT TO EACH MOTOR VEHICLE THAT I OWN,
PROCESSING OR AGENT
$
LICENSE OR OPERATE ON THE STREETS OR HIGHWAYS. ANY FALSE AFFIDAVIT IS A CRIME UNDER SECTION 575.050 OF MISSOURI LAW.
FEE
YOU MUST PRESENT YOUR INSURANCE CARD (A COPY IS ACCEPTABLE) OR OTHER ACCEPTABLE PROOF OF FINANCIAL RESPONSIBILITY.
SIGNATURE OF OWNER
FOR OFFICE USE ONLY
TOTAL FEES
$
Y
E
PP
FHVUT
INS.
X
VERIFIED BY
Y
E
Y E
SAFETY
EMISS
DRIVER LICENSE NUMBER/FEDERAL EMPLOYER IDENTIFICATION NUMBER
SURRENDERED PLATE NUMBER
SURRENDERED PLATE CREDIT
Notary Information Required for Replacement Plates and Non-Use Statement
NOTARY PUBLIC EMBOSSER OR
STATE
COUNTY (OR CITY OF ST. LOUIS)
BLACK INK RUBBER STAMP SEAL
SUBSCRIBED AND SWORN BEFORE ME, THIS
USE RUBBER STAMP IN CLEAR AREA BELOW
DAY OF
YEAR
NOTARY PUBLIC SIGNATURE
MY COMMISSION
EXPIRES
NOTARY PUBLIC NAME (TYPED OR PRINTED)
OFFICE VALIDATION ONLY
REMARKS
MO 860-0351 (08-2010)
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