APPLICATION FOR KENTUCKY CERTIFICATE OF TITLE ...

1 APPLICATION MUST BE COMPLETED IN BLUE OR BLACK INK TC 96-182 Rev. 9/ 08 Fee _____COMMONWEALTH OF KENTUCKYAPPLICATION FOR KENTUCKY CERTIFICATE OF TITLE / REGISTRATIONC heck the type of APPLICATION desired _____ oDuplicate oTitle Only oTransfer oFirst Time oSalvage oOther If Duplicate is checked, the original CERTIFICATE of TITLE is: _____ oLost oDestroyed oDamaged oIllegible oClassic TitleVehicle Identification Section_____VIN Make_____Year Body Style Model Model No. Color_____Motor No. Cylinders Truck Weight(if motorcycle) TITLE BRAND DISCLOSUREC heck appropriate block if: oRebuilt Vehicle oWater DamageWhen block is checked and TITLE does not include brand, provide jurisdiction _____and TITLE number _____ where previous brand was INSPECTOR SECTIONI, (Certified Inspector) _____Of _____ County Phone No.

2 (_____) _____Docertifyunder penalties that I have physically inspected the vehicle described herein to be roadworthy andthat the supporting documents are consistent with the vehicle VEHICLE HAS AN ODOMETER READING OF _____ NO TENTHSTHE VEHICLE IDENTIFICATION NUMBER IS:INSPECTION REQUESTEDBY _____OWNER DRIVER LICENSE NO. & STATE _____CERTIFIED INSPECTOR S SIGNATURE INSPECTOR NO. DATEODOMETER DISCLOSURE **CAUTION READ CAREFULLY BEFORE YOU CHECK A BLOCK**Federal law requires that you state the mileage upon transfer of ownership. Failure to complete or providing a false statement may result in fines and/or certify to thebest of my knowledge that the odometer reading is the actual mileage of the vehicle unless one of the following statements is (no tenths)o1. The mileage stated is in excess of its mechanical Readingo2. The odometer reading is not the actual mileage. WARNING ODOMETER CONSIDERATION AND TRADE-INFORMATIONG iving a false statement as to the total consideration paid is a Class D Felony with a minimum fine of $ Price $Trade In $Net Cost $Tax $_____(Credit allowed only on vehicles registered in KY and applicant has paid tax)Date of SaleTrade InMakeYearVIN and buyer further certify subject to penalties of forgery in the second degree, that each has supplied true and correct information to the best of his knowledge and belief, in this document, including the above OWNERSHIP:oORoANDNOTE.

3 If neither box is checked the TITLE Transfer will require both signatures_____NAME OF SELLERDEALER OF #BIRTH ADDRESSPHONE OF #BIRTH (ohave) (ohave not) applied fora loan in connection with the vehicle described herein and if not, I (owill) (owill not) apply for a loan within 30 days of this NAME OR OTHERFIRST LIENHOLDER_____LESSEE ADDRESSADDRESS_____CITYCOUNTYSTATEZIPCOU NTY LIEN TO BE FILED IN_____SELLER S SIGNATUREOWNER/BUYER(S) SIGNATURE(S)_____SELLER S SIGNATUREOWNER/BUYER(S) SIGNATURE(S)Date of Transfer _____Attesting OfficialTitleAttesting OfficialTitleSubscribed and sworn to before me this _____day of _____20 _____Subscribed and sworn to before me this _____day of _____20 _____My commission expires _____My commission expires _____COUNTY CLERK USE ONLYTYPE APPLICATIONDATE OF ISSUANCETITLE certify under above described penalty that I have reviewed this APPLICATION and the documents supporting it and that the same are present and consistent with this APPLICATION ; that I receivedthe APPLICATION on the date and time indicated hereonand that fees were collected as indicated.

4 I further certify that the required information has been entered into the automated vehicle identification system (AVIS). _____SIGNATURE & TITLE OF ISSUERCOUNTYDATEI certify that the lien indicated to be filed has been noted into the automated system and that a TITLE will be withheld for 30 days, or until financing statement and fees required are received, whichever occurs _____Date _____DO NOT ACCEPT TITLE SHOWING ANY ERASURES, ALTERATION, OR MUTILATIONS. MUST BE COMPLETED IN BLUE OR BLACK INK.