DMV-1L
West Virginia Department of Transportation
Rev. 03/2012
Division of Motor Vehicles
FOR DMV USE ONLY
Application for Certi cate of Title for a Leased Motor Vehicle
CLASS
TYPE OR PRINT IN BLUE OR BLACK INK
NUMBER
MAKE CHECKS PAYABLE TO DIVISION OF MOTOR VEHICLES
EX P. D ATE
INSTRUCTIONS ARE ON THE REVERSE SIDE OF THIS FORM.
LESSOR’S NAME
NAME OF PURCHASER TO BE WRITTEN PLAINLY AND EXACTLY AS IT IS TO APPEAR ON THE CERTIFICATE OF TITLE
C/O LESSEE’S NAME
LESSOR’S ADDRESS
NUMBER
STREET
CITY/TOWN
COUNTY
STATE
ZIP CODE
VEHICLE DESCRIPTION
Make
Year
V. I. N.
Odometer Reading
Style of Body
Weight
(No Tenths)
Passenger vehicle only
TRUCKS Requested (GVW)
Lease Permit
Base Lease
Term
Tax
in
Number
Payment
Months
Amount
TRADE IN DESCRIPTION
Make
Year
V. I. N.
WV Title No.
Cash Down or Rebate Amount
5% of Cash Down or Rebate Amount
(cap cost reduction)
REGISTRATION PLATE TRANSFERRED FROM VEHICLE BELOW - SEND COPIES OF BOTH SIDES OF REGISTRATION CARD.
Make
Weight
V. I. N.
Plate No.
LIENS AND ENCUMBRANCES
Name of Lien Holder
Amount
Mailing
Kind of Lien
C/S/C
D/T
S/A
Date
Address
Street
City
State
Zip Code
MOTOR VEHICLE INSURANCE POLICY INFORMATION - INSURANCE MUST BE IN EFFECT WHEN APPLICATION IS RECEIVED.
I hereby state that there is a motor vehicle liability policy in effect on the described vehicle in accordance with the provisions of the West Virginia Motor Vehicle
Laws and certify that the statements made herein are true and correct to the best of my knowledge and belief under penalty of false swearing. West Virginia
Motor Vehicle Law § 17A-9-1: Fraudulent Applications.
Effective date of insurance policy: From
To
THIS TITLE APPLICATION MUST BE SIGNED BY THE OWNER
Name of Insurance Company
Name of Insurance Agent
PRINT COMPANY NAME
(x)
Insurance Policy Number
National Association Insurance Commissioners (NAIC) Number
OWNER’S SIGNATURE - POWER IF ATTORNEY DOCUMENTS MUST BE
PROVIDED IF NOT SIGNED BY OWNER THEMSELVES.
DEALER CERTIFICATION
I hereby state that there is a motor vehicle liability policy in effect on the described vehicle in accordance with the provisions of the West Virginia Motor Vehicle
Laws and certify that the statements made herein are true and correct to the best of my knowledge and belief under penalty of false swearing. West Virginia
Motor Vehicle Law § 17A-9-1: Fraudulent Applications.
This is to certify that the above described vehicle was acquired from _____________________________________________________________________ on
MONTH ____________________
DAY _________
YEAR ___________ and leased to the above-named lessor on MONTH _______________________
DAY _________
YEAR ___________. The undersigned dealer further certifies that the lease payment, term, and tax are true and correct and that the
Federal Odometer Regulation has been satisfied.
FEDERAL ODOMETER REGULATIONS REQUIRE YOU STATE THE ODOMETER MILEAGE UPON TRANSFER OF OWNERSHIP.
I certify to the best of my knowledge that the odometer reading is _____________________ and reflects the actual mileage unless one of the following is checked:
1.) The mileage stated is in excess of it’s mechanical limits.
2.) The odometer reading is not the actual mileage. WARNING-ODOMETER DISCREPANCY.
Dealer Name
Dealer No.
(x)
Dealer Address
Dealer Signature