Louisiana Department of Public Safety and Corrections TO ...

1 VINMakeLicense DateBodyColorYearIf yes, what ward or district?Domicile CodeNameStreetTrade VINT rade License UsedStateLess TradeTax Value BE SURE TO SIGN AND DATEI do swearor affirm that the information containedin this documentis true andcorrect to the best of my the vehiclebeingregisteredis definedas a commercial motor vehicleby theFederal Motor Carrier Safety Regulations and/or Federal Hazardous MaterialRegulations,by signaturebelowregistrant declares knowledgeof those federalregulations.*Tax Penalty: 5% of sales tax due for 30 days or fraction thereof (not to . exceed 25%).*Interest: of sales tax due for 30 days or fraction thereof . (no maximum).PROOF OF LIABILITY INSURANCE MUST BE FURNISHED AS PROVIDED FOR BY LAW BEFORE THIS FILE CAN BE AVOID PENALTY AND INTEREST:Total FeesTotal TaxesGrand TotalTax CreditFile must be submitted within 40 days from the date of purchase.

2 For manufactured houses (mobile homes), file must be submitted by the 20th of the month following the month of certificate of title issued to me was . lost mutilated never received I make application for a duplicate copy of said certificate and agree to hold the Commissioner harmless if the previous title is obtained by another person. I give the Commissioner permission to mail the title to the address on this Transfer FeeLicense CreditLicense Penalty*Tax Penalty*InterestVendor's CompMortgage FeeTaxELECTRONIC LIEN TRANSFER CODEF irst Lienholder's NameTow FeeLicense FeeMiscellaneous FeeRebateTitle FeeLic Pen CreditHandling FeeDUPLICATE TITLE AFFIDAVIT (Must be signed by owner and notarized.)

3 Tax DatePrevious Title of VehicleCity/State/ZipSecond Lienholder's NameStreetCity/State/ZipType of PlateMileageStreet Lessee Mail To Domicile Renter If lessee, domicile, or renter is indicated, renewal notice should be mailed to (check one): . Owner Lessee, renter, or domicile addressDriver's License or EIN of Lessee or RenterCity Parish State/ZipDate PreparedYES NOCity Parish State/ZipLouisiana Department of Public Safety and CorrectionsOffice of Motor VehiclesTO AVOID REJECTION:Complete all required Box 64886, Baton Rouge, LA 70896-4886 ELECTRONIC FUND TRANSFER CODED river's License or EINIf vehicle is a manufactured home, is it used as a residence?

4 YES NODriver's License or EIN Co-Applicant's Signature DateOwner's Princi pal Residence Address (or Business Location if Vehicle is Used for Commercial Purposes)Are you residing within the corporate limits of municipality?YES NOAre you residing within a special tax district or ward?Date AcquiredRECEIVED/REJECTION DATE(S)VEHICLE APPLICATIONDEALER CODEVEHICLE IS SUBJECT TO SECURITY AGREEMENT AS FOLLOWS:AFFIDAVIT OF NON-POSSESSION OF TITLE BY LIENHOLDER. Must be signed by lienholder and hereby swear or affirm that title of above described vehicle showing lien in our favor was never received received and surrendered to the owner.

5 Lienholder's SignatureOwner(s)'s Signature(s) for Duplicate TitleModel/WeightName of OwnerName of Joint Owner (if applicable)Witness Witness Sworn and subscribed before me this _____ day of _____, _____I haveand will maintain, during this registration period, vehicleliabilityinsurance(security) requiredby LRST itle 32:861-865. Failureto maintainas agreedwillbe a violationof law which may resultin criminal prosecution and/or suspensionof registration Public Signature, Printed Name ID NumberWitness Witness Sworn and subscribed before me this _____ day of _____, _____Notary Public Signature, Printed Name ID Number Applicant's Signature OF , STOLEN, OR REPLACEMENT PLATESTICKERL icense Plate Number USE STATEMENTF.

6 OUT OF STATE DECLARATIONI, OF SALVAGE / RECONSTRUCTED / WATER DAMAGED / HAIL-DAMAGEDI, swear under penalties of perjury that:the title covering the vehicle,, in accordance withMAKEMODELVINL ouisiana 32 , has been branded:Salvaged VehicleReconstructed Vehicleto the following extent:to the following components:Power TrainComputerElectrical SystemHail-DamagedSigned by under penalties of perjury this day of, 20_____Owner's SignatureLicense plate _____ has been removed from a _____YEAR MAKE VINand transferred to the vehicle described on the first page of this form. License plate returned is _____I do declare that Iam a bonafide farmerand amin the businessof farming; that the vehicle describedon the firstpage ofthis formis usedprimarily,but notexclusively,in hauling farm produce raisedon my farm, from such farmto marketand return therefrom; haulingmerchandiseto my farmand that this vehicle willnot be usedto haulanother person's farm produceor other products for a feeorcompensation.

7 Said farm is located at:_____RFD Box City Parish ZipError: _____Correct To: _____Use _____Weight _____Use _____Weight _____NOTICE:If a title, license plate,orvalidation stickerisnotreceived within thirty (30) days after submitting application and fees for such,contact your nearest OfficeofMotor Vehicles. Departmental policy provides for the issuanceofa free replacement within sixty (60)days from the date of issuance. Failure to notify this office timely could result in additional fees being License Plate Number _____New License Plate Number _____(Printed name of owner)declare that the MAKEwas domiciled in Louisiana on (Printed name of owner)cosmetic damage caused by hail, equivalent to seventy-five percent or more of its market value as a result of costs or repairs to items such as windshield, windows, and rear glass; exterior paint and paint materials; and body damage such as dents.

8 (Signature of vehicle owner)False statements are punishable by fine, imprisonment or both under 32 accordance with Louisiana 32:789, the undersigned confirm that the above referenced vehicle has sustained water damageIn accordance with Louisiana 32:781, the undersigned confirm that the above referenced vehicle has sustained water damageIn accordance with Louisiana 32:702(13), the undersigned confirm that the above referenced vehicle has sustained only