Form Dpsmv 1799 - Vehicle Application Page 2
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1
2NOTICE:
If a title, license plate, or validation sticker is not received within thirty (30) days after submitting application and fees for such,
contact your nearest Office of Motor Vehicles. Departmental policy provides for the issuance of a free replacement within sixty (60)
days from the date of issuance. Failure to notify this office timely could result in additional fees being charged.
A.
CONVERSION
Old License Plate Number _____________________
New License Plate Number _____________________
Use _____________________
Use _____________________
Weight _____________________
Weight _____________________
B.
TRANSFER OF PLATE
License plate ___________________ has been removed from a _______________________________________________________
YEAR
MAKE
VIN
and transferred to the vehicle described on the first page of this form. License plate returned is ______________________________
C.
LOST, STOLEN, OR REPLACEMENT
PLATE
STICKER
License Plate Number ________________
D.
TITLE CORRECTION
Error: _____________________________________________________________________________________________________
__________________________________________________________________________________________________________
Correct To: ________________________________________________________________________________________________
__________________________________________________________________________________________________________
E.
FARM USE STATEMENT
I do declare that I am a bona fide farmer and am in the business of farming; that the vehicle described on the first page of this form is used
primarily, but not exclusively, in hauling farm produce raised on my farm, from such farm to market and return therefrom; hauling
merchandise to my farm and that this vehicle will not be used to haul another person's farm produce or other products for a fee or
compensation. Said farm is located at:
________________________________________________________________________________________________________________
RFD
Box
City
Parish
Zip
________________________________________________________________________________________________________________
Owner's Signature
F.
OUT OF STATE DECLARATION
I,
declare that the
(Printed name of owner)
MAKE
MODEL
VIN
was domiciled in Louisiana on
.
G.
DISCLOSURE OF SALVAGE / RECONSTRUCTED / WATER DAMAGED / HAIL-DAMAGED
I,
swear under penalties of perjury that:
(Printed name of owner)
the title covering the vehicle,
, in accordance with
MODEL
VIN
MAKE
Louisiana R.S. 32:706.1, has been branded:
Salvaged Vehicle
Reconstructed Vehicle
In accordance with Louisiana R.S. 32:789, the undersigned confirm that the above referenced vehicle has sustained water damage
to the following extent:
In accordance with Louisiana R.S. 32:781, the undersigned confirm that the above referenced vehicle has sustained water damage
to the following components:
Power Train
Computer
Electrical System
In accordance with Louisiana R.S. 32:702(13), the undersigned confirm that the above referenced vehicle has sustained only
cosmetic damage caused by hail, equivalent to seventy-five percent or more of its market value as a result of costs or repairs
to items such as windshield, windows, and rear glass; exterior paint and paint materials; and body damage such as dents.
Hail-Damaged
Signed by
under penalties of perjury this day of
(Signature of vehicle owner)
, 20
False statements are punishable by fine, imprisonment or both under R.S. 32:730.
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