Fillable Printable Car Registration Form - Kentucky
Fillable Printable Car Registration Form - Kentucky
Car Registration Form - Kentucky
KentuckyTransportationCabinet
DivisionofMotorVehicleLicensing
APPLICATIONFORKENTUCKYCERTIFICATEOFTITLEORREGISTRATION
TC96‐182
05/2013
Check the type of application desired ___________________________ Duplicate Title Only Transfer First Time Salvage Classic
If Duplicate is checked, the original Certificate of Title is: ____________
Lost Destroyed Damaged Illegible Other
Vehicle Identification Section
VIN Make
Year Body Style Model Model No. Color
Motor No. Cylinders Truck Weight
(if motorcycle)
CERTIFIED INSPECTOR SECTION
I, (Certified Inspector – Print Nam e)
of County, Phone No.
do certify under the penalty provisions of KRS 186A.115(4)(d) that I have physically
inspected the vehicle described herein to be roadworthy and that the supporting documents
are consistent with the vehicle description.
THE VEHICLE HAS AN ODOMETER READING OF NO TENTHS
THE VEHICLE IDENTIFICATION NUMBER IS:
INSPECTION REQUESTED
BY
OWNER DRIVER LICENSE NO. & STATE
_______________________________________ _________________________________
CERTIFIED INSPECTOR’S SIGNATURE INSPECTOR NO. DATE
TITLE BRAND DISCLOSURE
Check appropriate block if: Rebuilt VehicleWater Damage
If block is checked and title does not include brand, provide
jurisdiction and title number
if previous brand was
issued.
ODOMETER DISCLOSURE ****CAUTION READ CAREF ULLY BEFORE YOU CHECK A BLOCK****
49 USC Sec. 32705 and KRS 190.300 require that you state the mileage upon transfer of ownership. Failure to complete or providing a false statement may result in fines and
or imprisonment. I certify to the best of my knowledge tha t the odometer reading is the actual mileage of the vehicle unless one of the following statements is checked.
(notenths)1. The mileage stated is in excess of its mechanical limits.
Odometer Reading 2. The odometer reading is not the actual mileage. W ARNING – ODOMETER DISCREPANCY.
TOTAL CONSIDERATION AND TRADE-IN INFORMATION
Sale Price $ Trade In $ Net Cost $ Tax $
Date of Sale
Seller and buyer certify pursuant to the penalty provisions of KRS 190.990(5),that each has supplied true and correct total consideration information to the best of their knowledge and belief in this document, including the above affidavit.
JOINT OWNERSHIP: OR AND NOTE: If neither box is checked the Title Transfer shall require both signatures
NAME OF SELLER DEALER NO. NAME OF OWNER/BUYER S.S.#, KyDL#, or Govt. issued # BIRTH MO.
STREET ADDRESS PHONE NO. NAME OF OWNER/BUYER S.S.#, KyDL#, or Govt. issued # BIRTH MO.
CITY COUNTY STAT E ZIP STREET ADDRESS PHONE NO.
CITY COUNTY STATE ZIP
I (have) (have not) applied for a loan in connection with the vehicle described herein and if not, I ( will) ( will not) apply for a loan within 30 days of this application.
LESSEE NAME OR OTHER FIRST LIENHOLDER
LESSEE ADDRESS ADDRESS
CITY COUNTY STATE ZIP COUNTY LIEN TO BE FILED IN
SELLER’S SIGNATURE OWNER/BUYER(S) SI GNATURE(S)
SELLER’S SIGNATURE OWNER/BUYER(S) SI GNATURE(S)
Date of Transfer
_________________________________________________________ ________________________________________________________
Attesting Official Title Attesting Official Title
Subscribed and attested before me this
_______
day of
_______________
20
_____
Subscribed and attested before me this
_______
day of
_____________
20
_____
My commission expires
______________________________________ _____
My commission expires
______________________________________ ____
COUNTY CL ERK USE ONLY
TYPE APPLICATION
DATE OF ISSUANCE
TITLE NO.
PLATE NO.
I certify subject to the penalty provisions of KRS 190.990(5) that I have reviewed this application and the documents supporting it and that the same are present and consistent with this application; that I received the application on the date and
time indicated hereon and that fees were collected as indicated. I further certify that the required information has been entered into the automated vehicle identification system (AVIS).
__________________________________________________________________________________________________________________________________________________________________________________________________
SIGNATURE & TITLE OF ISSUER COUNTY DATE
I 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 first.
Signature _______________________________ ________________ Date _________________
DO NOT ACCEPT TITLE SHOWING ANY ER ASURES, ALTERATION, OR MUTILATIONS. MUST BE COMPLETED IN BLUE OR BLACK INK IF NOT COM PLETED ON-
LINE.
Make
Year
VIN No.
Title No.
Make
Year
VINNo.
Title No.
