Form Mvt 5-9 - Supporting Document To A Mail Order Application For Certificate Of Title Page 2
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1
2Part III
NOTICE OF SECURITY INTEREST
I am disclosing my Lienholder(s) as follows:
First Lienholder: (Write “NONE” under name if there are no liens and sign below.)
Name: _____________________________________________________________________________________________________
Address: ___________________________________________________________________________________________________
City: ______________________________________________ State: __________________________ Zip: ___________________
Lien Date: __________________________________________________________________________________________________
I, the undersigned, certify that the vehicle to be named in the application for certificate of title is free and clear of all encumbrances
or liens except that which is named above.
____________________________________________________
SIGNATURE OF OWNER(S)
NOTE: Failure to disclose a security interest with fraudulent intent is a felony offense.
Part IV
CERTIFICATION OF VEHICLE INSPECTION AND OWNER IDENTIFICATION
_______________________________________________________
_______________________________________________________
STATE OR FEDERAL LAW ENFORCEMENT AGENCY
NAME OF STATE
____________________________________________________________________________
_________ _________________________
MAILING ADDRESS
AREA CODE
TELEPHONE NO. AND EXTENSION
VEHICLE INFORMATION:
____________________________
____________ ___________________________ _______________________ ________________
MAKE
YEAR
MODEL
BODY TYPE
NO. OF CYLINDERS
___________________________________________ ___________________________ _________________________________________
VEHICLE IDENTIFICATION NUMBER
COLOR OF VEHICLE
ODOMETER READING
OWNER IDENTIFICATION: (One or all of the following.)
_____________________________________ _____________________________________
____________________________________
CURRENT DRIVERS LICENSE NO. AND STATE
SOCIAL SECURITY NUMBER
OTHER IDENTIFICATION
____________________________________________________
SIGNATURE OF OWNER(S)
(Print)
___________________________________________________________________________________________________________________
NAME OF OWNER(S) AS SHOWN ON IDENTIFICATION SOURCE ABOVE
I hereby certify that the vehicle described above was physically inspected by me and the owner(s) as named in Part II (Legal
Alabama Resident) of this form and as described above, have been identified by me and I have witnessed the signature(s). I fur-
ther certify that all the information shown above is true and correct to the best of my knowledge and belief.
(Print)
_______________________________________________________
_______________________________________________________
NAME OF INSPECTING OFFICER
SIGNATURE OF INSPECTING OFFICER
_______________________________________________________
BADGE OR IDENTIFYING NUMBER
_______________________________________________________
ADDRESS OF ORGANIZATION
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