MISSISSIPPI MOTOR TITLE APPLICATION

1 FOR OFICE USEDATERCVD. _____CASH $ _____CCK$_____ CCK#_____MO$_____ MO#_____MISSISSIPPI MOTOR TITLE APPLICATIOND epartment of Wildlife, Fisheries, and ParksBoat Registration1505 Eastover DriveJackson, MS REGISTRATION #(If related) TITLE #DATE OF ISSUEPROCESSED BY:CHECK THE APPLICABLE BOXES1. New MS MOTOR TITLE $ Corrected TITLE Only$ Transfer MS TITLE $ AMOUNT REMITTED$3. Duplicate TITLE $ requesting a duplicate please furnish information concerning the original certificate and the circumstances of its loss, theft, mutilation or CHECK OR MONEY ORDER PAYABLE TO MISSISSIPPI DEPT. OF WILDLIFE, FISHERIES, AND PARKSAPPLICANT SNAME (PRINT)LAST FIRST MIDDLEDATE OF BIRTHSOCIAL SECURITY NUMBERMAILINGADDRESSSTREET OR POST OFFICE BOX NUMBERHOME TELEPHONE NUMBERCITYS TAT CITIZEN?

2 YES NOWORK TELEPHONE NUMBERE-MAIL ADDRESSA CO-OWNER(IF APPLICABLE)LAST FIRST MIDDLEDATE OF BIRTHSOCIAL SECURITY NUMBERDESCRIPTION OFOUTBOARD MOTORMANUFACTURERHORSEPOWERMODEL YEARSERIAL #VALUE OF MOTORMOTOR IS SUBJECT TO THE FOLLOWING LIENSFIRST LIEN MOTOR ADDRESSCITY, STATE, ZIPTELEPHONENAME AND ADDRESS OF PERSON FROM WHOM MOTOR WAS PURCHASEDDATE OF LIEN$ AMOUNT OF LIEN -I CERTIFY THAT I OWN THE ABOVE MOTOR AND UNDERSTAND AND AGREE THAT AN EXAMINATION MAY BE MADE OF THE MOTOR BY THE STATE OF MISSISSIPPI , department OF WILDLIFE, FISHERIES AND OF _____ Appeared before me _____.

3 Who first being duly SWORN says that of his or her own personal knowledge all the information given and STATEMENTS made on the APPLICATION are true and correct and that the MOTOR described is subject to no liens or encumbrances except as noted on the THE _____ DAY OF _____, 20_____APPLICANT S SIGNATUREDRIVERS LICENSE S SIGNATUREMY COMMISSION EXPIRESCO-OWNER S SIGNATUREDRIVERS LICENSE S SIGNATUREDEALER PERMIT NUMBERM ississippi Code Section 97-7-10 states (in Part).. Whoever makes or uses any false, fictitious, or fraudulent statement or entry, shall, upon conviction be punished by a fine of not more than $10, or by imprisonment for not more than 5 years, or by both such fine and imprisonment.

4 Return White Copy - Keep Yellow CopyREV. 12/09 FOR OFFICE USEDATERCVD. _____CASH $ _____CCK$_____ CCK#_____MO$_____ MO#_____ MISSISSIPPI BOAT TITLE APPLICATIOND epartment of Wildlife, Fisheries, and ParksBoat Registration1505 Eastover DriveJackson, MS REGISTRATION #MI TITLE #DATE OF ISSUEPROCESSED BY:CHECK THE APPLICABLE BOXES1. New MS Boat TITLE $ Corrected TITLE Only$ Transfer MS TITLE $ AMOUNT REMITTED$3. Duplicate TITLE $ requesting a duplicate please furnish information concerning the original certificate and the circumstances of its loss, theft, mutilation or CHECK OR MONEY ORDER PAYABLE TO MISSISSIPPI DEPT. OF WILDLIFE, FISHERIES, AND PARKSAPPLICANT SNAME (PRINT)LAST FIRST MIDDLEDATE OF BIRTHSOCIAL SECURITY NUMBERMAILINGADDRESSSTREET OR POST OFFICE BOX NUMBERHOME TELEPHONE NUMBERCITYS TAT CITIZEN?

5 YES NOWORK TELEPHONE NUMBERE-MAIL ADDRESSA CO-OWNER(IF APPLICABLE)LAST FIRST MIDDLEDATE OF BIRTHSOCIAL SECURITY NUMBERDESCRIPTION OF BOATHULL IDENTIFICATION NUMBERMODEL YEARVALUE OF BOATMAKELENGTHFTINBOAT IS SUBJECT TO THE FOLLOWING LIENSFIRST LIEN BOATADDRESSCITY, STATE, ZIPTELEPHONENAME AND ADDRESS OF PERSON FROM WHOM BOAT WAS PURCHASEDDATE OF LIEN$ AMOUNT OF LIEN I CERTIFY THAT I OWN THE ABOVE BOAT AND UNDERSTAND AND AGREE THAT AN EXAMINATION MAY BE MADE OF THE BOAT BY THE STATE OF MISSISSIPPI , department OF WILDLIFE, FISHERIES AND OF _____ Appeared before me _____.

6 Who first being duly SWORN says that of his or her own personal knowledge all the information given and STATEMENTS made on the APPLICATION are true and correct and that the watercraft described is subject to no liens or encumbrances except as noted on the THE _____ DAY OF _____, 20_____APPLICANT S SIGNATUREDRIVERS LICENSE S SIGNATUREMY COMMISSION EXPIRESCO-OWNER S SIGNATUREDRIVERS LICENSE S SIGNATUREDEALER PERMIT NUMBERM ississippi Code Section 97-7-10 states (in Part).. Whoever makes or uses any false, fictitious, or fraudulent statement or entry, shall, upon conviction be punished by a fine of not more than $10, or by imprisonment for not more than 5 years, or by both such fine and imprisonment.

7 Return White Copy - Keep Yellow CopyREV. 12/09