Form 768 (Revised 05-2020)
Motor Vehicle Bureau Phone: (573) 526-3669
E-mail: [email protected]
Visit http://dor.mo.gov/motorv/
for additional information.
Certification
r The motor vehicle described on the attached application has not been operated on public roads or the highways of Missouri by
myself, or my agent during the period of __ __ /__ __ /__ __ __ __ to __ __ /__ __ /__ __ __ __. (*Notarization required)
r I am giving the unit described below to ____________________________________________________ and there is no money or other
valuableconsiderationinvolvedinthetransaction.(Note:inthisinstance,thiscompletedafdavitshouldbegiventothenewowneralong
with the assigned title. To notify the Department of Revenue that a transfer of ownership has occurred for a motor vehicle, trailer, all-terrain
vehicle (ATV), motorcycle, motortricycle, or autocycle, complete the tear-off Notice of Sale or Transfer (DOR-5049A) attached to the bottom
of the Missouri title or a Notice of Sale or Transfer (Form 5049) and submit the completed form to the address indicated on the form. The
original owner and the new owner are required to sign the Notice of Sale or Transfer form, even when gifting a motor vehicle, trailer, ATV,
motorcycle, motortricycle, or autocycle.)
r The motor vehicle described below has not been in the state of Missouri for the 60 day period immediately preceding the date of this
application for registration and will be submitted for inspection at an ofcial inspection station within 10 days after entering the state
by myself, or my agent.
r The abandoned property described below was abandoned on real estate owned or purchased by me located at (address, city, state, zip
code): _____________________________________________________________________________________________________
and has an approximate retail and or fair market value of $ __________________. Provide a detailed explanation as to the circumstances by
which the real estate owner came into possession of the abandoned property and why the real estate owner considers the unit has been
abandoned: __________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
r IcertifythatI amseventy-ve yearsold or older and am no longer required to present a physician’s statementat thetime ofrenewal
for disabled person placards or license plates.
r Fireghter Plates - I certify and afrm that I am a director of a re protection district, or are compensated, partially compensated,
or a volunteer member of a re department, re protection district, or voluntary re protection association in Missouri. I further afrm
that if I resign, are removed, or otherwise terminate my association with the re department, I will return my special license plates
totheMissouriDepartmentofRevenuewithin15days.(*Notarization required)
Name of Fire District ____________________________________________________________________________________
r Other _______________________________________________________________________________________________________
____________________________________________________________________________________________________________
Any false statement in this affidavit is a violation of law, and may be punished by fine, imprisonment, or both.
Owner Year Make Model
Vehicle Identification Number Original Title Number Current License Number
Signature of Owner Date (MM/DD/YYYY)
__ __ /__ __ /__ __ __ __
Notary Information
Subscribed and sworn before me, this
day of year
State County (or City of St. Louis) My Commission Expires (MM/DD/YYYY)
Notary Public Signature
Notary Public Name (Typed or Printed)
Embosser or black ink rubber stamp seal
__ __ /__ __ /__ __ __ __
Form
768
General Affidavit
*License Ofce notary service - $2.00
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