Missouri Lien Waiver Details

The Missouri lien form is a legal document that can be used to secure payment for services or goods provided. The form allows providers to file a notice of claim against the property or assets of the person or company who received the service or goods. The lien can then be used as leverage to collect payment for the services or goods provided. If you need to file a Missouri lien form, it's important to understand how it works and what protections it offers. Speak with an attorney if you have any questions about using this form in your business dealings.

You will discover more details concerning the missouri lien form by checking out the listing we put together.

QuestionAnswer
Form NameMissouri Lien Form
Form Length2 pages
Fillable?Yes
Fillable fields53
Avg. time to fill out11 min 10 sec
Other namesmissouri lien form, missouri lien entry form, lien waiver form missouri, lien waiver form

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MISSOURI DEPARTMENT OF REVENUE

 

MOTOR VEHICLE BUREAU

573-526-3669

PO BOX 3355, JEFFERSON CITY MO 65105-3355

www.dor.mo.gov/mvdl

NOTICE OF LIEN, LIEN RELEASE, OR AUTHORIZATION TO ADD/REMOVE NAME FROM TITLE

 

FOR DOR USE ONLY

REJECT NUMBER

Form

 

 

4809

 

TYPE ALL APPLICATIONS. IF NOT

(Revised 08-2019)

TYPED, ATTACH COPY OF TITLE.

 

 

 

FOR DOR USE ONLY

 

 

 

NOTICE OF LIEN (NO NOTARY REQUIRED)

 

 

 

 

 

 

 

 

 

 

IS THIS A CHANGE OF OWNERSHIP?

YES NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

OWNER INFORMATION

 

OWNER’S NAME (LAST, FIRST, MIDDLE) AS SHOWN ON TITLE APPLICATION (ONLY FIRST 50 CHARACTERS WILL PRINT ON TITLE)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

STREET ADDRESS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

COUNTY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CITY, STATE, AND ZIP CODE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DLN OR FEIN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

UNIT DESCRIPTION

 

  PASSENGER

 

  TRUCK

  ATV

 

  TRAILER

 

  MANUFACTURED HOME

  RV

 

  BUS

 

  BOAT/VESSEL       

 

 

 

 

 

  OUTBOARD MOTOR (EXCLUDING TROLLING MOTOR)

 

 

  MOTORCYCLE

 

  TRICYCLE

 

  AUTOCYCLE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YEAR

 

MAKE

 

 

 

 

 

 

 

 

VIN/HIN NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

__ __ __ __

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PURCHASE DATE

 

 

 

 

 

PREVIOUS TITLE NUMBER

 

 

 

 

 

NET PRICE (AFTER TRADE-IN)

 

 

 

 

 

 

 

 

__ __ /__ __ /__ __ __ __

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LIENHOLDERFIRST INFORMATION

 

LIENHOLDER’S NAME AS SHOWN ON TITLE APPLICATION

 

 

 

 

 

 

 

 

 

 

FDIC OR LIENHOLDER ID NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

STREET ADDRESS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CITY, STATE, AND ZIP CODE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LIEN DATE

 

 

 

 

 

SUBJECT TO FUTURE ADVANCES?

 

LOAN OR UNIT NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

__ __ /__ __ /__ __ __ __

 

 

 

 

  YES

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FIRST LIENHOLDER AUTHORIZES A SECOND LIEN BY SIGNING BELOW

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LIENHOLDERSECOND INFORMATION

 

__ __ /__ __ /__ __ __ __

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FDIC OR LIENHOLDER ID NUMBER

 

 

 

 

 

 

 

 

LIENHOLDER’S NAME AS SHOWN ON TITLE APPLICATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

STREET ADDRESS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CITY, STATE, AND ZIP CODE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LIEN DATE

 

 

 

 

 

LOAN OR UNIT NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LIENHOLDER AUTHORIZATION FOR OWNERS TO ADD/REMOVE NAME FOR TITLE. (NO NOTARY REQUIRED)

 

 

 

 

 

 

 

 

 

 

ADD/REMOVE TITLEFROMNAME

 

OWNER’S NAME (LAST, FIRST, MIDDLE) AS SHOWN ON TITLE APPLICATION

 

 

PRINT NAME BEING ADDED OR REMOVED

 

ADD REMOVE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

STREET ADDRESS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CITY, STATE, AND ZIP CODE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

COUNTY

 

TITLE NUMBER

 

 

 

 

PRINTED NAME OF LIENHOLDER’S AGENT

 

 

 

SIGNATURE OF LIENHOLDER’S AGENT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YEAR

 

MAKE

 

 

 

 

 

 

 

VIN/HIN NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

__ __ __ __

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LIEN RELEASE—ATTACH TO TITLE

ANY PERSON WHO KNOWINGLY AND INTENTIONALLY SUBMITS A SEPARATE DOCUMENT

 

 

 

 

 

 

RELEASING A LIEN OF ANOTHER WITHOUT THE AUTHORITY

 

TO DO SO SHALL BE GUILTY OF

 

 

 

 

(NOTARY REQUIRED)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

A CLASS D FELONY. (301.640 RSMo)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

RELEASE/NOTARY INFORMATION

 

LIENHOLDER’S NAME AS SHOWN ON TITLE

 

 

 

 

PRINTED NAME OF LIENHOLDER’S AGENT

 

 

 

 

 

SIGNATURE OF LIENHOLDER’S AGENT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NOTARY PUBLIC EMBOSSER OR BLACK

 

STATE

 

COUNTY (OR CITY OF ST. LOUIS)

LIEN CREATION DATE

 

 

 

RELEASE DATE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

RUBBER STAMP SEAL

 

 

 

 

 

 

 

 

 

 

 

 

 

__ __ /__ __ /__ __ __ __

 

__ __ /__ __ /__ __ __ __

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SUBSCRIBED AND SWORN BEFORE ME, THIS

 

 

 

 

 

 

 

 

 

MY COMMISSION EXPIRES

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DAY OF

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LIEN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NOTARY PUBLIC SIGNATURE

 

 

 

 

 

NOTARY PUBLIC NAME (TYPED OR PRINTED)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

A $6.00 processing fee must be submitted with each Notice of Lien.

THE ORIGINAL DOCUMENT MUST BE SUBMITTED. It is recommended that you retain a copy for your records.

Form 4809 (Revised 08-2019)

NOTICE OF LIEN

PLEASE PERFECT YOUR LIEN IMMEDIATELY!

IMPORTANT: Liens must be filed and/or received with the Department within 30 days of the loan date (perfected) for the lienholder to be protected from the debtor filing for bankruptcy relief.

A $6.00 processing fee must be submitted with each Notice of Lien.

OWNER INFORMATION AND UNIT DESCRIPTION — Complete all applicable blocks.

FIRST LIEN — Complete the FIRST LIENHOLDER INFORMATION section, if applicable.

SECOND LIEN — Complete the FIRST and SECOND LIENHOLDER INFORMATION sections, if applicable.

First Lienholder Authorization — This block must be signed by the first lienholder when adding a second lien.

Checks may be accepted as payment. Make checks payable to: Missouri Department of Revenue. The check must be pre-printed with the check writer’s name, address, bank code, and account number. It must also include the following information regarding the check writer:

1.Driver license or non-driver license number;

2.Date of birth; and

3.Daytime phone number.

Other restrictions may apply. NOTE: The Missouri Department of Revenue may electronically resubmit checks returned for insufficient or uncollected funds.

The lienholder will receive a receipt as proof the lien has been perfected.

Submit the completed Notice of Lien (Form 4809) to your local license office or by mail to the following address:

MOTOR VEHICLE BUREAU

301 WEST HIGH STREET

PO BOX 3355

JEFFERSON CITY MO 65105-3355

LIEN RELEASE

OWNER INFORMATION AND UNIT DESCRIPTION SECTIONS — Complete all applicable blocks.

FIRST AND SECOND LIENHOLDER SECTIONS — Leave blank.

LIEN RELEASE SECTION — Enter the lienholder’s name as shown on title, the date of release, printed name of the lienholder’s agent, and signature of lienholder’s agent.

NOTARIZATION — The notary information is required to be completed to release the lien.

NOTE: License Office notary service - $2.00

FRAUDULENT LIEN RELEASE — ANY PERSON WHO KNOWINGLY AND INTENTIONALLY SUBMITS A SEPARATE DOCUMENT RELEASING A LIEN OF ANOTHER WITHOUT THE AUTHORITY TO DO SO SHALL BE GUILTY OF A CLASS D FELONY. (301.640, RSMo)

Form 4809 (08-2019)

How to Edit Missouri Lien Form

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