Form Tc 96-187e - Title Lien Statement - Kentucky Transportation Cabinet

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KENTUCKY TRANSPORTATION CABINET
TC 96-187E
07/2001
Division of Motor Vehicle Licensing
TITLE LIEN STATEMENT
ORIGINAL FILING
CONTINUATION
TERMINATION
______________________
# _______________________________
Original File #
Original File
____________________
_____________________________
Original File Date
Original File Date
1. Debtor(s) (Last Name First) and Address
2. Secured Party and Address
For Filing Officer
(Date, Time, Number and Filing Officer)
4.
This Title Lien Statement covers the following:
YEAR MODEL
MAKE
VEHICLE IDENTIFICATION NUMBER
ADDITIONAL DESCRIPTION
___________
__________________
_______________________________
_________________________________
___________
__________________
_______________________________
_________________________________
___________
__________________
_______________________________
_________________________________
___________
__________________
_______________________________
_________________________________
___________
__________________
_______________________________
_________________________________
___________
__________________
_______________________________
_________________________________
__________________________________________________
___________________________________________________
Authentication of Debtor(s)
Authentication of Secured Party(s)
__________________________________________________
___________________________________________________
Date
Date
The following are required:
FILING OFFICER COPY
LIENHOLDER ACKNOWLEDGEMENT COPY
DEALER/SECURED PARTY COPY
DEBTOR COPY

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