Form Rt Ds-50.5 Out-Of State Salvage Vehicle Buyer Application
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1
2OUT-OF STATE SALVAGE VEHICLE
JESSE WHITE
QUANTITY
SCHEDULE OF FEES
AMOUNT
SECRETARY OF STATE
BUYER APPLICATION
STATE OF ILLINOIS
__________
Certificate of Authority – Annual Fee ................................ $100.00
__________
__________
For First Registration, June 15th thru Dec. 31st .......... 50.00
__________
__________
Additional Identification Cards ................................................ 5.00
__________
FOR OFFICE USE ONLY
LICENSE YEAR ENDING DECEMBER 31, ___________
Description of Draft, Check
DRS# __________________________
OSB# ________________________________________
Remittance:
Postal or Exp. M.O. # ................................................. TOTAL FEE
__________
Type or
Do not send currency or stamps, remittance must be in the form of check, draft or money order and must
Print Firm's
be payable to Secretary of State.
Legal Name
Business
Address
City
State
ZIP Code
or
Town
MAIL APPLICATIONS TO:
JESSE WHITE
Business Telephone No.
Secretary of State
VEHICLE SERVICES DEPARTMENT
DEALER LICENSING SECTION
I certify I am licensed in the state of _____________________________________ equivalent to an Illinois
ROOM 069
(check one)
REBUILDER
SCRAP PROCESSOR
AUTOMOTIVE PARTS RECYCLER
SPRINGFIELD, ILLINOIS 62756
I have attached a photocopy of my home state license.
TYPE OF BUSINESS ENTITY:
Proprietorship
Partnership
Other
I HEREBY ATTEST AND DULY VERIFY THAT ALL OF THE INFORMATION CONTAINED IN THIS
Trust
Corporation (If corporation, give date of incorporation) _____________________
APPLICATION ON BOTH FRONT AND BACK, IS TRUE AND CORRECT TO THE BEST OF MY KNOW-
LIST BELOW the names and residence addresses of the proprietor, each partner, member or trustee. If a
LEDGE AND I FURTHER CERTIFY THAT I HAVE READ AND UNDERSTAND THE STATEMENT AND
corporation, list below the names and residence addresses of all officers, directors and shareholders having a
10 percent or greater ownership interest in the corporation.
AFFIDAVIT CONTAINED ON THIS APPLICATION.
Name
Residence Telephone
Driver's License No.
____________________________________________________________
_____________________
WRITTEN SIGNATURE OF AUTHORIZED PERSON
DATE
Street Address
City, State and ZIP Code
Your signature authorizes the Secretary of State to lower the amount of your check if fee submitted is greater
than the required fee for mail-in transactions.
Name
Residence Telephone
Driver's License No.
Subscribed and sworn to before me this __________ day of ___________________________ , _______ .
Street Address
City, State and ZIP Code
(SEAL)
______________________________________________________
Name
Residence Telephone
Driver's License No.
(Notary Public)
Street Address
City, State and ZIP Code
Name
Residence Telephone
Driver's License No.
Street Address
City, State and ZIP Code
Name
Residence Telephone
Driver's License No.
Street Address
City, State and ZIP Code
Name
Residence Telephone
Driver's License No.
Street Address
City, State and ZIP Code
IF ADDITIONAL SPACE IS NEEDED ATTACH A SEPARATE LISTING
RT DS-50.5
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