Form Dpsmv 1799 - Vehicle Application

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Louisiana Department of Public Safety and Corrections
TO AVOID REJECTION:
Office of Motor Vehicles
ELECTRONIC FUND
P.O. Box 64886, Baton Rouge, LA 70896-4886
Complete all required information
TRANSFER CODE
VEHICLE APPLICATION
Date Prepared
Type of Plate
DEALER CODE
VIN
Make
License No.
Exp. Date
Body
Color
Year
Mileage
Model/Weight
If vehicle is a manufactured home, is it used as a residence?
YES
NO
Name of Owner
Driver's License or EIN
Name of Joint Owner (if applicable)
Driver's License or EIN
Owner's Pricipal Residence Address (or Business Location if Vehicle is Used for Commercial Purposes)
Are you residing within the corporate limits of municipality?
YES
NO
City
Parish
State/Zip
Are you residing within a special tax district or ward?
YES
NO
If yes, what ward or district?
If lessee, domicile, or renter is indicated, renewal notice should be mailed to (check one):
Domicile Code
Lessee
Mail To
Domicile
Renter
Owner
Lessee, renter, or domicile address
Name
Driver's License or EIN of Lessee or Renter
Street
Trade VIN
City
Parish
State/Zip
Trade License No.
VEHICLE IS SUBJECT TO SECURITY AGREEMENT AS FOLLOWS:
First Lienholder's Name
Second Lienholder's Name
ELECTRONIC LIEN
TRANSFER CODE
Street
Street
City/State/Zip
City/State/Zip
Date Acquired
Tax Date
Previous Title No.
State
Cost of Vehicle
Less Trade
New
Used
Title Fee
Lic Pen Credit
Handling Fee
Rebate
Tax Value
Mortgage Fee
Tax
Tow Fee
DUPLICATE TITLE AFFIDAVIT (Must be signed by owner and notarized.)
License Fee
*Tax Penalty
Miscellaneous Fee
The certificate of title issued to me was
lost
mutilated
never received
Lic Transfer Fee
*Interest
Total Fees
I make application for a duplicate copy of said certificate and agree to hold the
License Credit
Vendor's Comp
Total Taxes
Commissioner harmless if the previous title is obtained by another person.
License Penalty
Tax Credit
Grand Total
I give the Commissioner permission to mail the title to the address on this
application.
BE SURE TO SIGN AND DATE
Owner(s)'s Signature(s) for Duplicate Title
I do swear or affirm that the information contained in this document is true and
correct to the best of my knowledge.
I have and will maintain, during this registration period, vehicle liability insurance
Witness
Witness
(security) required by LRS Title 32:861-865. Failure to maintain as agreed will
Sworn and subscribed before me this ________ day of ____________, _______
be a violation of law which may result in criminal prosecution and/or suspension
of registration privileges.
Notary Public Signature, Printed Name
ID Number
If the vehicle being registered is defined as a commercial motor vehicle by the
AFFIDAVIT OF NON-POSSESSION OF TITLE BY LIENHOLDER
Federal Motor Carrier Safety Regulations and/or Federal Hazardous Material
Must be signed by lienholder and notarized.
Regulations, by signature below registrant declares knowledge of those federal
regulations.
I hereby swear or affirm that title of above described vehicle showing lien in our
favor was
never received
received and surrendered to the owner.
Applicant's Signature
Date
Co-Applicant's Signature
Date
Lienholder's Signature
PROOF OF LIABILITY INSURANCE MUST BE FURNISHED AS
PROVIDED FOR BY LAW BEFORE THIS FILE CAN BE PROCESSED.
Witness
Witness
Sworn and subscribed before me this ________ day of ____________, _______
TO AVOID PENALTY AND INTEREST:
File must be submitted within 40 days from the date of purchase. For
manufactured houses (mobile homes), file must be submitted by the 20th of the
month following the month of delivery.
Notary Public Signature, Printed Name
ID Number
RECEIVED/REJECTION DATE(S)
*Tax Penalty: 5% of sales tax due for 30 days or fraction thereof (not to
exceed 25%).
*Interest: 1.25% of sales tax due for 30 days or fraction thereof
(no maximum).

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