5091 Form PDF Details

The Form 5091 plays a crucial role in safeguarding the privacy and integrity of personal and vehicle information, adhering strictly to both federal and state laws. This form, administered by the Missouri Department of Revenue's Motor Vehicle and Driver Licensing Division, requires thorough completion and approval before an applicant can access restricted motor vehicle or driver license records. It meticulously caters to various requesters, including government agencies, law enforcement entities, businesses engaging in fraud prevention, and insurance companies, among others, each seeking information for legitimate and authorized purposes as defined under the Federal Driver’s Privacy Protection Act (DPPA) and Missouri law. The form outlines a detailed process for requesting and utilizing sensitive data, emphasizing the legal responsibilities of the requester to avoid unauthorized disclosure. Additionally, it provides options for retrieving information on vehicle ownership, title history, mileage, and more. The intricate structure of Form 5091 not only ensures the legitimate use of personal information but also underlines the comprehensive measures taken to prevent its misuse, highlighting the balance between accessibility and privacy protection.

QuestionAnswer
Form Name5091 Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesSR-22, form 5091, MISSOURI, missouri department of revenue forum 5091

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COUNTY (OR CITY OF ST. LOUIS)
USE RUBBER STAMP IN CLEAR AREA BELOW.
TITLE OF CORPORATE OFFICER, NEWS AGENT, OR GOVERNMENT AGENT

MISSOURI DEPARTMENT OF REVENUE

MOTOR VEHICLE AND DRIVER LICENSING DIVISION — RECORD SALES

PO BOX 2167, JEFFERSON CITY MO 65105-2167

(573) 526-3669

FAX: (573) 526-7367

www.dor.mo.gov

REQUEST FOR MOTOR VEHICLE/DRIVER LICENSE RECORDS/PERSONAL INFORMATION

FORM

5091

(REV. 07-2011)

INSTRUCTIONS: THIS APPLICATION MUST BE COMPLETED AND APPROVED BEFORE AN APPLICANT CAN OBTAIN RESTRICTED INFORMATION. ONLY APPLICANTS WHO MEET THE CRITERIA OUTLINED IN SECTION B ARE ELIGIBLE TO OBTAIN RESTRICTED INFORMATION.

SECTION A. REQUESTER INFORMATION (THIS SECTION MUST BE COMPLETED BY ALL.)

 

NAME OF INDIVIDUAL OR ORGANIZATION

TELEPHONE NUMBER

FAX NUMBER

 

 

(

)

 

 

 

 

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

REQUESTER NAME

Check

 

Individual

Partnership

 

News Media

 

 

 

 

one:

 

Corporation

Government Agent

LLC

 

 

 

 

 

 

 

 

 

 

 

 

ADDRESS

CITY

 

 

STATE

 

 

 

 

ZIP CODE

 

 

 

 

 

 

 

 

 

 

 

 

MAILING ADDRESS (IF DIFFERENT)

CITY

 

 

STATE

 

 

 

 

ZIP CODE

 

 

 

 

 

 

 

 

 

 

 

 

DESCRIBE THE PRIMARY FUNCTION OF YOUR BUSINESS

 

 

 

 

E-MAIL

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DESCRIBE HOW THE INFORMATION WILL BE USED

 

 

 

 

 

 

 

 

 

 

 

SECTION B. AUTHORIZATION (THIS SECTION MUST BE COMPLETED BY ALL.)

Requester hereby certifies to the Missouri Department of Revenue (Department) that this request for Missouri motor vehicle and/or driver license records or information is made under the provisions of the Federal Driver’s Privacy Protection Act (DPPA) and Missouri law. Please review and carefully check all boxes that apply to requester to obtain personal information on a restricted record. Requester is seeking information:

(01) As a government agency (federal, state, or local) or on behalf of a government agency, in carrying out its government functions.

(02) As a court (federal, state, or local) or on behalf of a court, in carrying out its court functions.

(03) As a law enforcement agency (federal, state, or local) or on behalf of a law enforcement agency, in carrying out its law enforcement functions.

(04) For use in connection with matters of motor vehicle or driver safety and theft; motor vehicle emissions, motor vehicle product alterations, recalls, or advisories; performance monitoring of motor vehicles, motor vehicle parts and dealers; motor vehicle market research activities, including survey research; and removal of non-owner records from the original owner records of motor vehicle manufacturers.

(05) For use as a legitimate business only (a) to verify the accuracy of personal information submitted by an individual to the business or its agents, employees, or contractors and (b) if such information is not correct, to obtain the correct information, but only for the purposes of preventing fraud by pursuing legal remedies, or recovering on a debt or security interest, against the individual. (For individual requests only.)

(06) For use in connection with any civil, criminal, administrative, or arbitral proceeding in any federal, state, or local court or agency or before any self-regulatory body, including the service of process, investigation in anticipation of litigation, and the execution or enforcement of judgments and orders, or pursuant to an order of a federal, state, or local court.

(07) For use in research activities, and producing statistical reports, so long as the personal information is not published, redisclosed, or used to contact individuals.

(08) As an insurer, insurance support organization, or self-insured entity for use in connection with claims investigation activities, antifraud activities, rating or underwriting.

(09) For use in providing notice to the owners of towed or impounded vehicles.

(10) For use by a licensed private investigative agency or licensed security service for a purpose permitted herein.

(11) For use as an employer, its agent or insurer in obtaining or verifying motor vehicle/driver record information relating to a holder of a commercial driver’s license (CDL).

(12) For use in the operation of a private toll transportation facility.

(13) To disseminate to the public in a newspaper, book, magazine, broadcast, or similar form of public communication, when such dissemination is related to the operation of a motor vehicle or to public safety.

Requester certifies under penalty of perjury that: 1) all information on this application has been read and understood; 2) all information completed on this application is true and correct; and 3) the willful and unauthorized disclosure of information obtained from any Department record may result in penalties imposed under Title 18 U.S.C. Section 2724.

Requester understands that Section 302.183.2, RSMo, prohibits the sale of data derived from a person’s driver’s license application for commercial purposes, which includes purposes motivated primarily by financial gain such as, but not limited to, surveys, marketing or solicitations, without the express consent of the person to whom such information pertains. Requester shall not sell personal information for commercial purposes without such consent.

SIGNATURE(S) OF INDIVIDUAL, PARTNERS (ALL REQUIRED), AUTHORIZED MEMBER OR CORPORATE OFFICER, NEWS AGENT, OR GOVERNMENT AGENT

PRINTED NAME(S)

NOTARY INFORMATION

NOTARY PUBLIC EMBOSSER OR BLACK RUBBER STAMP SEAL

STATE

SUBSCRIBED AND SWORN BEFORE ME, THIS

 

 

DAY OF

YEAR

NOTARY PUBLIC SIGNATURE

MY COMMISSION

 

EXPIRES

 

 

 

NOTARY PUBLIC NAME (TYPED OR PRINTED)

MO 860-3062 (07-2011)

PAGE 2

SECTION C. REQUEST TO OBTAIN MISSOURI VEHICLE INFORMATION

VEHICLE OWNER’S NAME — LAST, FIRST, MIDDLE INITIAL

VEHICLE OWNER’S STREET ADDRESS, R.R., OR P.O. BOX NUMBER

INFORMATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MOTOR VEHICLE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1

 

YEAR

 

MAKE

TITLE NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

VEHICLE IDENTIFICATION NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

VEHICLE

LICENSE PLATE NUMBER

 

 

 

 

 

 

EXPIRATION YEAR

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2

 

YEAR

 

MAKE

TITLE NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MOTOR

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

VEHICLE IDENTIFICATION NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LICENSE PLATE NUMBER

 

 

 

 

 

 

EXPIRATION YEAR

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CITY

 

 

STATE

 

ZIP CODE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

INFORMATION

 

 

 

 

 

 

 

MARINE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YEAR

MAKE

DECAL NUMBER

EXPIRATION YEAR

 

 

1

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

IDENTIFICATION NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CRAFT

ADDITIONAL INFORMATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2

 

YEAR

MAKE

DECAL NUMBER

EXPIRATION YEAR

MARINE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

IDENTIFICATION NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ADDITIONAL INFORMATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CHECK INFORMATION TYPE (RECORDS MAY BE CERTIFIED):

CURRENT OWNER/LIENHOLDER - Requester will receive only the name and address of the latest owner and lienholder when applicable on file.

TITLE HISTORY - Requester will receive a list that shows each time the ownership changed in this state, including the names and addresses of the owners. MILEAGE HISTORY - Requester will receive a list that shows each time the ownership changed in this state, including the mileage, title numbers, and issue dates. NAME HISTORY - Requester will receive a list of the current vehicles registered in the owner’s name.

SECTION D. REQUEST TO OBTAIN MISSOURI DRIVER RECORD INFORMATION

NAME OF RECORD HOLDER— LAST, FIRST, MIDDLE INITIAL

MISSOURI DRIVER LICENSE NUMBER

SOCIAL SECURITY NUMBER

DATE OF BIRTH

 

 

 

I HEREBY REQUEST THE FOLLOWING RECORD (PLEASE MARK THE APPROPRIATE BOX(ES):

THE FEE IS $5.88 PER RECORD.

DRIVER RECORD*

 

IMAGE PORTFOLIO (LICENSE PHOTO)

CASE HISTORY*

 

 

HARDSHIP PACKAGE__________________________________________

 

 

 

A CASE HISTORY CONSISTS OF ANY OPEN CASE OR ANY REINSTATEMENT

A HARDSHIP PACKAGE CONSISTS OF A CERTIFIED DRIVER RECORD AND A CERTIFIED SR-22.

OR TERMINATION CASE NOT LESS THAN TWO YEARS OLD.

 

 

 

 

 

CASE DOCUMENT (SPECIFY)*

 

OTHER (SPECIFY)

_____________________________________________

 

 

 

 

 

REINSTATEMENT NOTICE

 

_____________________________________________________________

 

 

 

 

 

SUSPENSION NOTICE

 

 

 

 

CONVICTION (TICKET# ____________________)

 

_____________________________________________________________

 

 

 

 

 

SR-22

 

 

 

*RECORDS MAY BE CERTIFIED

 

 

 

 

 

PLEASE SEND THE ABOVE RECORD(S) BY

 

 

 

 

MAIL and/or

FAX (add $0.50 per page faxed)

CHECK IF CERTIFIED RECORD REQUESTED

 

 

 

 

 

 

 

PAYMENT OPTIONS

Records can be obtained by walk- in, mail-in, or e-mail request.

The fee is $5.88 per record.

A convenience fee will be charged for credit/debit card transactions.

 

PAYMENT

CENTRAL

 

FAX OR

 

OFFICE

MAIL

 

OPTIONS

E-MAIL

 

VISIT

 

 

 

 

 

 

CASH

a

 

 

 

CHECK

a

a

 

 

MONEY ORDER

a

a

 

 

DEBIT CARD

a

 

 

 

DISCOVER

a

a

a

 

VISA

a

a

a

 

AMERICAN EXPRESS

a

a

a

 

MASTERCARD

a

a

a

TOTAL RECORD FEES

CONVENIENCE FEE

$0.00 - $33.00

$1.00

$33.01 - $100.00

3.00%

$100.01 - $250.00

2.95%

$250.01 - $500.00

2.85%

$500.01 - $750.00

2.85%

$750.01

- $1,000.00

2.80%

$1,000.01

- $1,500.00

2.75%

$1,500.01

- $2,000.00

2.70%

$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 360, 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

__ __ / __ __

REQUESTER’S SIGNATURE

PRINTED NAME

THE MISSOURI DEPARTMENT OF REVENUE MAY ELECTRONICALLY RESUBMIT CHECKS RETURNED FOR INSUFFICIENT OR UNCOLLECTED FUNDS

MO 860-3062 (07-2011)

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missouri department of revenue forum 5091 completion process outlined (stage 1)

2. After the last segment is done, it is time to add the required particulars in For use in connection with, For use as a legitimate business, For use in connection with any, For use in research activities, individuals, As an insurer insurance support, or underwriting, For use in providing notice to, For use by a licensed private, For use as an employer its agent, drivers license CDL, For use in the operation of a, To disseminate to the public in a, related to the operation of a, and Requester certifies under penalty so you can move on to the 3rd part.

Part no. 2 for filling in missouri department of revenue forum 5091

3. Completing PRINTED NAMES, TITLE OF CORPORATE OFFICER NEWS, NOTARY INFORMATION NOTARY PUBLIC, STATE, SUBSCRIBED AND SWORN BEFORE ME THIS, COUNTY OR CITY OF ST LOUIS, NOTARY PUBLIC SIGNATURE, DAY OF, YEAR MY COMMISSION EXPIRES, USE RUBBER STAMP IN CLEAR AREA, NOTARY PUBLIC NAME TYPED OR PRINTED, and MO is essential for the next step, make sure to fill them out in their entirety. Don't miss any details!

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4. Filling out SECTION C REQUEST TO OBTAIN, VEHICLE OWNERS STREET ADDRESS RR, CITY, STATE, ZIP CODE, YEAR, MAKE, TITLE NUMBER, MOTOR VEHICLE, VEHICLE IDENTIFICATION NUMBER, N O T A M R O F N, E L C H E V R O T O M, LICENSE PLATE NUMBER, EXPIRATION YEAR, and YEAR is key in the next form section - make sure to take the time and take a close look at each and every empty field!

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