Form Tc 96-182 - Application For Kentucky Certificate Of Title/registration

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APPLICATION MUST BE COMPLETED IN BLUE OR BLACK INK
TC 96-182 Rev. 1/2000
COMMONWEALTH OF KENTUCKY
APPLICATION FOR KENTUCKY CERTIFICATE OF TITLE/REGISTRATION
Check the type of application desired
Duplicate
Title Only
Transfer
First Time
Salvage
Other
If Duplicate is checked, the original Certificate of Title is:
Lost
Destroyed
Damaged
Illegible
Other
Vehicle Identification Section
CERTIFIED INSPECTOR SECTION
I, (Certified Inspector)
VIN
Make
O f
County Phone No. (
)
Do certify under penalties that I have physically inspected the vehicle described
Year
Body Style
Model
Model No.
Color
herein and that the supporting documents are consistent with the vehicle description.
THE VEHICLE HAS AN ODOMETER READING OF
NO TENTHS
Motor No.
Cylinders
Truck Weight
THE VEHICLE IDENTIFICATION NUMBER IS:
(if motorcycle)
TITLE BRAND DISCLOSURE
INSPECTION REQUESTED
Check appropriate block if:
Rebuilt Vehicle
Water Damage
BY
When block is checked and title does not include brand, provide
OWNER DRIVER LICENSE NO. & STATE
jurisdiction
and title number
where previous brand was issued.
CERTIFIED INSPECTOR’S SIGNATURE
INSPECTOR NO.
DATE
ODOMETER 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 imprisonment.
I certify to the best of my knowledge that the odometer reading is the actual mileage of the vehicle unless one of the following statements is checked.
(no tenths)
1. The mileage stated is in excess of its mechanical limits.
2. The odometer reading is not the actual mileage. WARNING - ODOMETER DISCREPANCY
Odometer Reading
TOTAL CONSIDERATION AND TRADE-INFORMATION
Giving a false statement as to the total consideration paid is a Class D Felony with a minimum fine of $2000.
Sale Price $
Trade In $
Net Cost $
Tax $
(Credit allowed only on vehicles registered in KY and applicant has paid tax.)
Make
Year
VIN No.
Title No.
{
Trade In
Make
Year
VIN No.
Title No.
Date of Sale
Seller 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 affidavit
JOINT OWNERSHIP:
OR
AND
NOTE: If neither box is checked the Title Transfer will require both signatures
NAME OF SELLER
DEALER NO.
NAME OF OWNER/BUYER
S.S.#
BIRTH MO.
STREET ADDRESS
PHONE. NO.
NAME OF OWNER/BUYER
S.S.#
BIRTH MO.
CITY
COUNTY
STATE
ZIP
ADDRESS
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) SIGNATURE (S)
SELLER’S SIGNATURE
OWNER/BUYER (S) SIGNATURE (S)
Date of Transfer
Attesting Official
Title
Attesting Official
Title
Subscribed 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 ONLY
TYPE APPLICATION
DATE OF ISSUANCE
TITLE NO.
PLATE NO.
I 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 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 ERASURES, ALTERATIONS, OR MUTILATIONS. MUST BE COMPLETED IN BLUE OR BLACK INK.

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