TRANSFEREE / BUYER’S SIGNATURE DATE X APPLICATION FOR CERTIFICATE OF TITLE (Type or Print in Ink) Additional fee of $5.00 for failure to apply for title within 30 days of assignment. Type of Title Requested Salvage Salvage Replacement Salvage Duplicate (Check One) Lost Stolen Destroyed APPLICANT’S / BUYER’S PRINTED NAME SSN / EIN APPLICANT’S / BUYER’S PRINTED ADDRESS CITY STATE ZIP PURCHASE PRICE TAX PAID IF TAX EXEMPT, STATE REASON VENDOR NUMBER $ $ Condition of Vehicle (Check Only One) Good Fair Poor Wrecked Print Title YES NO Lien Information: If no lien, state If more than one lien, attached statement of all additional liens. “none”. LIENHOLDER’S PRINTED NAME LIENHOLDER’S ADDRESS CITY STATE ZIP NOTE: All blank spaces above must be completed before acknowledgement. If not applicable, insert NA or NONE in the space provided. I (we) state that all information contained in this application is true and correct. APPLICANT’S / BUYER’S SIGNATURE DATE X Notary: Sworn to and subscribed in my presence this day of , 20 in County, State of . (Notary Seal) X Signature of Notary Public My commission expires
TRANSFEREE / BUYER’S SIGNATURE X DATE APPLICATION FOR CERTIFICATE OF TITLE (Type or Print in Ink) Additional fee of $5.00 for failure to apply for title within 30 days of assignment. Type of Title Requested Salvage Salvage Replacement Salvage Duplicate (Check One) Lost Stolen Destroyed APPLICANT’S / BUYER’S PRINTED NAME SSN / EIN APPLICANT’S / BUYER’S PRINTED ADDRESS CITY STATE ZIP PURCHASE PRICE $ TAX PAID $ IF TAX EXEMPT, STATE REASON VENDOR NUMBER Condition of Vehicle (Check Only One) Good Fair Poor Wrecked Print Title YES NO Lien Information: If no lien, state “none”. If more than one lien, attached statement of all additional liens. LIENHOLDER’S PRINTED NAME LIENHOLDER’S ADDRESS CITY STATE ZIP NOTE: All blank spaces above must be completed before acknowledgement. If not applicable, insert NA or NONE in the space provided. I (we) state that all information contained in this application is true and correct. APPLICANT’S / BUYER’S SIGNATURE X DATE Notary: Sworn to and subscribed in my presence this day of , 20 in County, State of . (Notary Seal) Signature of Notary Public X My commission expires
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