Missouri Department of Revenue - Motor Vehicle Forms · Missouri state form
5317 Agreement to Pay Judgments
Form 5317 lets a self-insurer agree to pay judgments for accidents occurring while its certificate of self-insurance is in force.
- What this form is
- Use Form 5317 to document a self-insurer’s agreement to pay judgments for accidents occurring while its certificate of self-insurance is in force. The form requests the self-insured person’s printed name, signature, and date, and includes a declaration under penalties of perjury. The signature must be notarized, with a notary completing the jurat and identifying information.
- Who needs it
- A person acting as a self-insurer who needs to agree to pay judgments for accidents while a certificate of self-insurance is in force.
- Why it needs a notary
- The form includes a “Subscribed and sworn before me” jurat, so the signature must be notarized. This can be done online with a commissioned online notary.
- How to submit it
- Mail the completed form to Driver License Bureau, P.O. Box 200, Jefferson City, MO 65105-0200. The form also lists phone, fax, and email contact information.
Questions
What is Form 5317 used for?
Form 5317 documents a self-insurer’s agreement to pay the same judgments and amounts an insurer would have been obligated to pay under an owner’s motor vehicle liability policy.
Who completes Form 5317?
The form is completed by a self-insurer. It requests the self-insured person’s printed name, signature, and date, along with a declaration that the information is true, complete, and correct.
Does Form 5317 need to be notarized?
Yes. The form includes a “Subscribed and sworn before me” jurat, so the signature must be notarized. This can be done online with a commissioned online notary.