State Form 44049 - Application For Certificate Of Title - Indiana Bureau Of Motor Vehicles

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APPLICATION FOR CERTIFICATE OF TITLE

STATE OF INDIANA

BUREAU OF MOTOR VEHICLES

State Form 44049 (R3 / 1-98)

Approved by State Board of Accounts 1998

I/WE THE UNDERSIGNED SWEAR OR AFFIRM THAT THE INFORMA-

TO BE COMPLETED BY A POLICE OFFICER, BMV OFFICIAL OR BMV CERTIFIED DEALER SIGNEE

FOR OUT OF STATE TITLES.

I H EREBY C ERTIFY THAT I PER SON ALLY EXAM-

TION ENTERED ON THIS FORM IS CORRECT. I/WE UNDERSTAND

INED THE FOLLOWING VEHICLE AND FIND THE IDENTIFICATION NUMBER TO BE AS FOLLOWS.

THAT MAKING A FALSE STATEMENT ON THIS FORM MAY CONSTI-

TUTE THE CRIME OF PERJURY. FUTHERMORE, I/WE AGREE TO

VEHICLE IDENTIFICATION NUMBER

INDEMNIFY AND HOLD HARMLESS THE INDIANA BMV FROM ANY

LIABILITY ARISING FROM THIS TRANSACTION.

YR.

MAKE

MODEL

TYPE

DATE

X __________________________________________________________

INSPECTOR'S PRINTED NAME & TITLE

CITY

DATE: ______________________________________________________

The law requires that you apply for Certificate of Title within thirty-one days from the date of purchase of a

INSPECTOR'S SIGNATURE

BADGE, BRANCH OR

motor vehicle. There is a delinquent fee of $15.00 for failure to do so. Attach Certificate of Title assigned by seller. On en-

dorsed Titles, liens must be released. Supporting documents surrendered with this application cannot be returned to the appli-

DEALER PLATE NO.

cant. State fee for applying for Title is $11.00. *In accordance with Federal Code 383.

TITLE NUMBER

BRANCH NO.

INVOICE NO.

BMV USE ONLY

*SOC. SEC./FEDERAL I.D.NO.

APPLICANT'S NAME

BMV USE ONLY

STREET ADDRESS

CITY

STATE

ZIP CODE

VEHICLE I.D. NUMBER

VEH.YEAR

VEH. MAKE

VEH. MODEL NO. VEH TYPE

ODOMETER

FORMER TITLE NUMBER

PURCHASE DATE

LIEN

SPEED

PICK UP

MAIL

DEALER NO.

BMV USE ONLY

FIRST LIEN'S NAME OR SPECIAL MAILING ADDRESS

STREET ADDRESS

CITY

STATE

ZIP CODE

BMV USE ONLY

SECOND LIEN'S NAME

STREET ADDRESS

CITY

STATE

ZIP CODE

LICENSE NUMBER

LICENSE

FORMS

BMV USE ONLY

YEAR

USED

GROSS RETAIL & USE TAX AFFIDAVIT - I/WE HEREBY CERTIFY THAT SALES OR USE TAX ON THIS VEHICLE WAS PAID AS INDICATED BELOW.

SELLING PRICE

LESS TRADE-IN *

AMOUNT SUBJECT TO TAX AMOUNT OF TAX

DEALER

BRANCH

EXEMPT

IF EXEMPT

10.

PLACE PARA.#

*Your Social Security number / Federal I.D. number is being requested by this agency under IC 4-1-8-1. Disclosure is manadatory and this document cannot be processed without it.

APPLICANT RESPONSIBLE FOR ACCURACY OF INFORMATION

APPLICATION FOR CERTIFICATE OF TITLE

STATE OF INDIANA

BUREAU OF MOTOR VEHICLES

BUREAU - TO BE MAILED WITH TITLE REPORT