Form 411179 - Application For Certificate Of Title And/or Registration For A Leased Vehicle

APPLICATION FOR CERTIFICATE OF TITLE AND/OR REGISTRATION FOR A LEASED VEHICLE

(Check one) Send the registration renewal to the:

Owner

Lessee

Registration Month________________

Form 411179 (06-06)

(Check one) Registration refunds shall be made payable to the:

Owner

Lessee

OWNER INFORMATION (Leasing Company)

Present to County Treasurer of lessee’s residence if GVWR is less than 10,000lbs. If the GVWR is 10,000lbs or more, present to the Treasurer of the owner’s residence or if a non-resident to the Treasurer where the primary user resides.

Owner

Iowa DL # or Iowa ID # or Social Security #

:_______________________________________________________________________________________

:________________________________________________

First Name

Middle Name

Last Name

(If individual)

Leasing License Number

Birth Date

Federal Employer Identification #

________________________

:________________________________

:__________________________________________________________

(If individual)

(If organization)

Bona fide Residence Address of Owner

:__________________________________________________________________________________________________________________________________________________________

Address

City

County

State

Zip Code

Mailing Address of Owner

:________________________________________________________________________________________________________________________________________________________________________

Address

City

County

State

Zip Code

LESSEE INFORMATION (Required only if GVWR is less than 10,000lbs)

Lessee #1

Iowa DL # or Iowa ID # or Social Security #

:____________________________________________________________________________________

:________________________________________________

First Name

Middle Name

Last Name

(If individual)

Birth Date

Federal Employer Identification #

:________________________________

:__________________________________________________________

(If individual)

(If organization)

Bona fide Residence Address of Lessee #1

:_______________________________________________________________________________________________________________________________________________________

Address

City

County

State

Zip Code

Mailing Address of Lessee #1

:_____________________________________________________________________________________________________________________________________________________________________

Address

City

County

State

Zip Code

Lessee #2

Iowa DL # or Iowa ID # or Social Security #

:____________________________________________________________________________________

:________________________________________________

First Name

Middle Name

Last Name

(If individual)

Birth Date

Federal Employer Identification #

:________________________________

:__________________________________________________________

(If individual)

(If organization)

Bona fide Residence Address of Lessee #2

:________________________________________________________________________________________________________________________________________________________

Address

City

County

State

Zip Code

Mailing Address of Lessee #2

:____________________________________________________________________________________________________________________________________________________________________

Address

City

County

State

Zip Code

PRIMARY USER INFORMATION (Complete only if the lessee is not the primary user)

Primary User #1

Iowa DL # or Iowa ID #

:____________________________________________________________________________________

:____________________________________________________________________

First Name

Middle Name

Last Name

(If individual)

Birth Date

Federal Employer Identification #

:________________________________

:__________________________________________________________

(If individual)

(If organization)

Bona fide Residence Address of Primary User #1

:__________________________________________________________________________________________________________________________________________________

Address

City

County

State

Zip Code

Mailing Address of Primary User #1

:_______________________________________________________________________________________________________________________________________________________________

Address

City

County

State

Zip Code

Primary User #2

Iowa DL # or Iowa ID #

:____________________________________________________________________________________

:____________________________________________________________________

First Name

Middle Name

Last Name

(If individual)

Birth Date

Federal Employer Identification #

:________________________________

:__________________________________________________________

(If individual)

(If organization)

Bona fide Residence Address of Primary User #2

:__________________________________________________________________________________________________________________________________________________

Address

City

County

State

Zip Code

Mailing Address of Primary User #2

:______________________________________________________________________________________________________________________________________________________________

Address

City

County

State

Zip Code

VEHICLE INFORMATION

VIN________________________________________________________Year______________Make__________________________Model_______________________Type(car, truck,etc)_______________Style___________Color_________

Fuel____________ Cylinders________Tonnage___________GVWR______________Sq.Footage______________Iowa Plate Number (If applicable)____________Validation Number__________________________Validation Year__________

Purchase Date or Date Brought Into State__________________VIN of traded vehicle (if applicable)_______________________________________________________Trailer Empty Weight (If applicable)

Over 2000lbs

2000lbs or less

SECURITY INTEREST INFORMATION

Give complete statement of security interests (liens). If none, so state:______________________

Nature

Held By

Address (Street, City, State, Zip Code)

First Security

Interest

Federal Employer Identification # or Social Security #:

Second Security

Interest

Federal Employer Identification # or Social Security #:

Third Security

Interest

Federal Employer Identification # or Social Security #:

PURCHASE PRICE

THE FOLLOWING FOR DEALER USE ONLY:

The vehicle dealer named below as “seller” does hereby certify that the new

Total Lease Price

$_____________

(for motor vehicles with a GVWR less than 16,000, excluding motorcycles and mopeds)

vehicle described above was sold to the applicant for the following consideration which includes freight, manufacturer’s tax,

accessories, and other added equipment or services and represents the total delivered price to the purchaser, valued in

money whether received in money or otherwise

(Check only if applicable)

I claim exemption from payment of Iowa Use Tax. List Exemption Code________________

Sale Price.....................................................................$________________

Date Registration Applied For Card Issued

(See Page 2)

I/We certify under penalty of perjury that the foregoing is true and correct*

Less Trade-In ...............................................................$________________

If none, so state:____________________

Less Non-Taxable Charges (specify) ..........................$________________

Registration Fee Collected:____________

X_________________________________________________________________________________________

Less Rebate applied to purchase price of the vehicle .$________________

Signature of Owner

Date

Equals Tax Price ..........................................................$________________

By_______________________________________________________________________

If Firm, Association, Corporation, or Attorney in Fact

I/We certify under penalty of perjury that the foregoing is true and correct.

_____________________________________________________________________________________________

*Important

: Be certain that dates and other information given are correct. Any person who uses a false or fictitious

Date

Dealer No.

Dealership Name

name, makes a false statement or otherwise commits a fraud upon this application is punishable by prison sentence and

possible fine. This application also constitutes an application for refund of excess credit, when applicable.

By___________________________________________________________________________________________

Authorized Representative & Title

Yes, I would like to make a voluntary contribution to the anatomical gift public awareness and transplantation fund in the amount of $ _________________________