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MISSOURI DEPARTMENT OF REVENUE FORM

MOTOR VEHICLE AND DRIVER LICENSING DIVISION
REQUEST FROM RECORD HOLDER
4681
(REV. 09-2009)

Barbara J (Brush) Pierce

I hereby certify that my name is ______________________________________________________.
(First Name) (Middle Initial) (Last Name)

06-24-69
I further certify that my date of birth is _________________, 493-82-9211
that my Missouri driver license number is ___________________,
(Month/Day/Year)

212 Rose Ave. Taft Ca. 93268

that my present mailing address is ________________________________________________________________________
(Street) (Apartment/Unit) (City) (State) (Zip Code)

6 ___
and that my daytime telephone number is (___ 6 ___)
1 ___
6 ___
2 ___
3 - ___
3 ___
2 ___
5 ___
2 .
(Include Area Code)

I am requesting the following records (including my personal information on those records):

MOTOR VEHICLE RECORDS:
____________________________________ _____________________________________
Year-Make-VIN Registration (Plate) Number

Title record (specify current or history) Registration record (license plates)

Lienholder information Other(specify) ________________
✔ DRIVER LICENSE RECORDS:
Copy of application (specify year) _______ Image portfolio (black and white permit/license photo)
✔ Driver record Clearance letter (no fee required).
Other (specify) ____________________ Phone number (573) 751-2730
Temporary Driving Privilege_______(no fee required)
PLEASE SEND THE REQUESTED RECORD(S) BY
✔ MAIL and/or FAX (add $0.50 per page faxed)
PAYMENT OPTIONS
CENTRAL TOTAL RECORD FEES CONVENIENCE FEE
Records can be PAYMENT FAX OR
OFFICE MAIL $0.00 - $33.00 $1.00
obtained by walk-in, OPTIONS E-MAIL
VISIT


mail-in, or e-mail $33.01 - $100.00 3.00%
CASH



request. $100.01 - $250.00 2.95%
CHECK



The fee is $5.88 $250.01 - $500.00 2.85%
MONEY ORDER
per record.


$500.01 - $750.00 2.85%


DEBIT CARD
DISCOVER

$750.01 - $1,000.00 2.80%




A convenience fee
will be charged for $1,000.01 - $1,500.00 2.75%




VISA
credit/debit card AMERICAN EXPRESS $1,500.01 - $2,000.00 2.70%




transactions.
MASTERCARD $2,000.01 or more 2.60%
Mail to: Motor Vehicle and Driver License Bureau-Record Sales, PO Box 2167, Jefferson City, MO 65105-2167
Fax or E-Mail to: (573) 526-7367 dlrecords@dor.mo.gov
Visit at: Central Office, Harry S Truman Building, Room 370, 301 West High Street, Jefferson City, MO

If you are paying by credit/debit card you must provide the following:
NAME (AS IT APPEARS ON CARD) CARD TYPE CARD NUMBER EXPIRATION DATE

__ __ / __ __
I hereby authorize the Missouri Department of Revenue to fax ✔ mail this record information to:
Barbara J. (Brush) Pierce
Name: ___________________________________________ Fax: ( ___ ___ ___ ) ___ ___ ___ - ___ ___ ___ ___

Agency Name (if applicable) ____________________________________________________________________

212 Rose Ave. Taft,Ca 93268
Address: ____________________________________________________________________________________

RECORD HOLDER’S SIGNATURE DATE

__ __ / __ __ / __ __ __ __
NOTARY INFORMATION
NOTARY PUBLIC EMBOSSER OR STATE COUNTY (OR CITY OF ST. LOUIS)
BLACK 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)

THE MISSOURI DEPARTMENT OF REVENUE MAY ELECTRONICALLY RESUBMIT CHECKS RETURNED FOR INSUFFICIENT OR UNCOLLECTED FUNDS
MO 860-2768 (09-2009) DOR-4681 (09-2009)