Form 78-006 - Application For Replacement Certificate Of Title - Mississippi State Tax Commission
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1
2DO NOT WRITE IN THIS SPACE
Form 78-006
Rev. 06/04
Type or
Type or
Application for Replacement Certificate of Title
Print Only
Print Only
MAKE
YEAR
VEHICLE IDENTIFICATION NUMBER
TITLE NUMBER
Owner's Last Name
FIRST NAME(S)
MIDDLE NAME
Street, RFD
CITY
STATE
ZIP
CERTIFICATION
I/We, the registered owner or lienholder of the above described vehicle, hereby make application for a Replacement Certificate of Title and certify that the
original has been (Check appropriate box.)
Lost
Never received from the Department
Mutilated, Destroyed or Illegible:
Stolen;
Never received from the Lienholder;
Other (State why replacement is applied for if none of above apply)
I/We understand that upon issuance of the Replacement, the original Title becomes void and that I am required to return the original
Title to the State Tax Commission promptly should it be found. I also understand that the Replacement shall contain the legend "This
is a Replacement Certificate and may be subject to the rights of a person under the original Certificate."
MADE BY OWNER,
If there was a lienholder shown in the original Title, you must include application for lien
release. Replacement Certificate of Title, NO LIENS RECORDED ON ORIGINAL TITLE
READ &
Application must be signed by owner or owners (if more than one).
CHECK
HERE
MADE BY LIENHOLDER
Replacement Certificate of Title, LIEN RECORDED ON ORIGINAL TITLE - If lienholder directs State Tax Commis-
sion to mail title to owner, a completed application for release of lien, form 78-020, must be attached. When
lienholder's application fails to include LIEN RELEASE, title will be mailed to lienholder as shown on title.
Applicant hereby directs the State Tax Commission to mail or deliver the title herein applied for as shown below.
I, the undersigned hereby certify that I am the recorded owner or lienholder of the above described vehicle.
COMPLETE THIS SECTION, PRINTING OR TYPING ALL INFORMATION
Owner's Signature
IF NAME
ENTERED HERE
Joint Owner's Signature
IS OTHER
THAN TITLE
(TYPE OR PRINT NAME)
OWNER.
ATTACH
Lienholder's Name
APPROPRIATE
POWER OF
ATTORNEY.
Agent
DEALERS
(TYPE OR PRINT STREET ADDRESS)
(Signature of Lienholder Authorized Representative)
ATTACH COPY 3
OF FORM
65-099.
OTHERS USE
,
20
Date
65-016
MONTH
DAY
YEAR
NOTARIZED.
CITY
(TYPE OR PRINT)
STATE
ZIP
Fee for Replacement Title is payable by Cashier's Check,
FEE OF $4.00
Certified Check or other form of Certified funds.
TO:
STATE TAX COMMISSION
DO NOT SEND CASH THROUGH THE MAIL.
TITLE BUREAU, P. O. BOX 1383 JACKSON, MS 39215
SEE INSTRUCTIONS ON
REVERSE SIDE OF FORM
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