Application For Duplicate Certificate Of Title - Mass Rmv Page 2
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1
2I, We, the undersigned, hereby authorize the Registry of Motor Vehicles to mail to the dealership identified
below a duplicate Certificate of Title to be issued in my name in order to transfer ownership of the motor vehicle
described herein. Note, this form does not constitute a Power of Attorney or a Reassignment.
Name of Transferee/Dealer
Address
Dealer Registration Number
Year
Make
VIN
I state that the odometer now reads___________________(no tenths) and that to the best of my
knowledge it reflects the actual mileage of the vehicle unless one of the following statements is
checked:
q
I certify that, to the best of my knowledge, the odometer reading reflects the amount of mileage
in excess of its mechanical limits. (The odometer starting at zero again.)
q
I certify the odometer reading is not the actual mileage. "WARNING—Odometer Discrepancy"
Signature(s) of Transferrer(s)—Owner(s) as It(They) Appear(s) on Title
Printed Name(s)
Date
Make check or money order payable to:
MassDOT
Do Not Mail Cash
T20558-0112
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