Missouri Department of Revenue - Motor Vehicle Forms · Missouri state form
Form 5689 Self-Insurance Affidavit for Religious Groups
Form 5689 is an affidavit for a religious denomination requesting a certificate of self-insurance and affirming its members’ vehicle ownership, religious tenets, and ability to pay judgments.
- What this form is
- A religious denomination uses Form 5689 to request a certificate of self-insurance. The affidavit states that members are discouraged from purchasing insurance for religious reasons, that more than 25 members own motor vehicles, and that the denomination can pay judgments. The form calls for an attached list of members and vehicle details, along with signatures from an authorized representative or agent and a notary.
- Who needs it
- A religious denomination with more than 25 members who own motor vehicles and seek a certificate of self-insurance may use this affidavit.
- Why it needs a notary
- The authorized representative’s signature must be notarized. This can be done online with a commissioned online notary.
- How to submit it
- Mail the completed affidavit and attached member and vehicle list to the Driver License Bureau at the mailing address printed on the form.
Questions
Is Form 5689 an affidavit?
Yes. Form 5689 is titled “Self-Insurance Affidavit for Religious Groups” and is used to request a certificate of self-insurance.
Does Form 5689 need to be notarized?
Yes. The form includes a notary jurat and requires the authorized representative’s signature to be notarized. This can be done online with a commissioned online notary.
What must be attached to Form 5689?
Attach a list of members’ names and addresses and descriptions of their vehicles, including year, make, model, VIN, and current registration plate number.