HTML Preview Legal Business Bill Of Sale page number 1.
Year Make Model Vehicle Identification Number (VIN) Date Acquired from Owner
Name of Scrap Metal Operator
Street Address City State Zip
You must include a copy of the state identification (driver license, nondriver license, or state identification card) of the vehicle owner listed above
with this bill of sale or it will be rejected. Any misinformation provided on this bill of sale or any failure on your part to comply with Section 301.227,
RSMo, may result in disciplinary action on your salvage dealer license, if applicable.
If seller is an individual, complete the following:
I certify that I have legal authority to sell or otherwise transfer my interest in the motor vehicle or parts of the motor vehicle described on this bill
of sale.
____________________________________ ____________________________________ __ __ / __ __ / __ __ __ __
Seller’s Signature Printed Name Date (MMDDYYYY)
If person delivering the vehicle described on this bill of sale is different than the seller identified on this bill of sale, provide the following information
relating to the person delivering the vehicle (if the person delivering the vehicle is the same as the seller, indicate “same” in the area below).
____________________________________ ____________________________________ _____________________
Name of Person Delivering Vehicle Driver License Number State Issuing Driver License
If seller is an insurance company or an agent for an insurance company, complete the following:
____________________________________ ____________________________________ _____________________
Name of Insurance Company Loss Claim Number NAIC Number
__ __ / __ __ / __ __ __ __
Kind Of Vehicle (Click on vehicle type below)
P - Passenger M - Motorcycle
T - Truck C - Tricycle
B - Bus A - ATV R - Rec. Vehicle
Form
5423
Missouri Department of Revenue
Bill of Sale For Scrap Metal Operators –
Vehicles Ten Years or Older Without Title
This bill of sale is to be completed under Section 301.227, RSMo, by a scrap metal operator who acquires 1) a motor vehicle that is inoperable and at least
ten years old or 2) parts from a motor vehicle that is inoperable and at least ten years old without obtaining the certificate of title. Scrap metal operators
must have an account established and access to the Department’s online record inquiry system in order to fulfill their legal requirements prior to submitting
this bill of sale. Information regarding access to the online system can be found at: http://dor.mo.gov/motorv/liendeal/nol/index.php.
Business
Information
Vehicle
Information
Vehicle is being:
r
Retained for Resale of Parts (must have an active salvage dealer’s license,
provide dealer number below and include $2.50 for junk certificate).
Salvage Dealer Number ___________________________________
r
Destroyed
Seller’s
Information
Seller’s Name
Street Address City State Zip
Seller’s
Certification
Scrap Metal Operator’s
Certification of Facts
I certify the following under penalties of perjury:
• The vehicle identified on this bill of sale was acquired from the seller named above;
• The vehicle identified on this bill of sale is inoperable due to the vehicle being in a rusted, wrecked, discarded, worn out, extensively
damaged, dismantled, and mechanically inoperative condition; and
• If the vehicle is fewer than 20 years old, I have accessed the Department of Revenue’s online record access system and have
determined that the vehicle identified on this bill of sale is not subject to any recorded security interest or lien.
____________________________________ ____________________________________ __ __ / __ __ / __ __ __ __
Signature of Business Owner or Agent Printed Name Date (MMDDYYYY)
Mail this completed bill of sale with a copy of the seller’s identification to:
Motor Vehicle Bureau
P.O Box 2076 Phone: (573) 526-3669
Visit http://dor.mo.gov/motorv/
for additional information.
Form 5423 (Revised 08-2013)
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