Free power of attorney  08
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Form

4054

Missouri Department of Revenue
Power of Attorney

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I (we) hereby appoint, __________________________________________________ as my (our) attorney-in-fact for the
(If insurance company involving total loss, complete boxes immediately below.)

Insurance Company Name

Date of Total Loss

__ __ /__ __ /__ __ __ __

purpose of:
r Transferring ownership for the following described unit:
r Making application for title for the following described unit:
r Making application for registration for the following described unit:
Year (YYYY)

Make

Identification Number

with the full authority to sign on my (our) behalf all papers and documents and to do all that is necessary to this appointment.
Owner’s Printed Name

Owner’s Signature*

Date (MM/DD/YYYY)

__ __ /__ __ /__ __ __ __
Signature

Owner’s Printed Name

Owner’s Signature*

Date (MM/DD/YYYY)

__ __ /__ __ /__ __ __ __
Owner’s Printed Name

Owner’s Signature*

Date (MM/DD/YYYY)

__ __ /__ __ /__ __ __