Form Ta-Vd-119 - Vehicle Registration Application
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1
2
3DEPARTMENT USE ONLY – DO NOT WRITE IN SHADED AREAS
490
C or
EXPIRES
REG TYPE
INDEX #
OLD #1
#2
490
P
IN LIEU PLATE
TEMP PLATE DATE
/
NEW #1
TITLE CODE
225
227
231
232
233
452
453
454
455
465
LP
2 Year
1A
TRANSACTION TYPE
1B
PLATE TYPE
SCHOOL BUS (19)
ATV (02)
MUNICIPAL (15)
VFW (52)
PLEASURE CAR (19)
CONSERVATION PLATE (48, 57)
EMS (46)
FREEMASONS (54)
PLATE #____________________
US VET (49)
VANITY
BUILDING BRIGHT FUTURES (55)
VOLUNTEER (28)
ROTARY (53)
NATIONAL GUARD (41)
NEW (421)
DISABLED PLATE
OFF-HWY TRACTOR (24)
FIREFIGHTER (40)
MOTOR BUS (04, 05)
PURPLE HEART (47)
TRANSFER (431)
TRUCK (27)
AGRICULTURE (01)
FARM USE ONLY
JITNEY/RENTAL (37)
STATE (22)
POW (23)
RENEW (475)
TRAILER (26, 25, 06)
SPECIAL PURPOSE TRK CAT I (11)
ANTIQUE (03) (AN)
STREET ROD (56)
VIETNAM VET (50)
REPLACEMENT PLATE
MOTORCYCLE (18)
SPECIAL PURPOSE TRK CAT II (20)
FARM TRACTOR (45)
EXHIBITION (09) (EX)
AMERICAN LEGION
(38)
LOST
STOLEN
SEIZED
MOTOR HOME (19)
AMATEUR RADIO OPR (42)
Motor Driven Cycle (17)
LIONS CLUB (51)
IRP TAX & TITLE
WEIGHT CHANGE
MAKE
MODEL
MODEL YEAR
BODY TYPE
MILEAGE (NO TENTHS)
MILES
COLOR
2
KM
HOURS
SERIAL NUMBER (VIN)
NO OF CYL
GAS
DIESEL
HYBRID
VEHICLE IS
ELECTRIC
PROPANE
OTHER
NEW
USED
REBUILT
TRUCKS
MOTORCYCLE
3A
3B
3C
3D
TRAILERS
BUS/JITNEY/RENTAL
includes Pick-Up & AGRICULTURE VEHICLES
ATV/MDC
EMPTY
LOADED
EMPTY
EMPTY
# Wheels
CC’s
WEIGHT OF
WEIGHT
WEIGHT
WEIGHT
WEIGHT
TRAILER & LOAD
# OF AXLES
BRAKE TYPE
LENGTH x WIDTH (FT)
# OF
1499 lbs or less (26)
PASSENGERS
HYD
AIR
OTHER
1500 lbs or more (25)
LOADED
WEIGHT
VT DRIVER LICENSE NO
SSN or FEDERAL ID NUMBER
VT DRIVER LICENSE NO
SSN or FEDERAL ID NUMBER
GENDER
GENDER
OWNER
CO-OWNER
4A
M
F
M
F
LESSEE
LESSOR
Name
Name
Mailing Address (PO Box or Street)
Mailing Address (PO Box or Street)
City:
State:
ZIP:
City:
State:
ZIP:
Physical Address (Street)
Physical Address (Street)
City:
State:
ZIP:
City:
State:
ZIP:
DATE OF BIRTH
IF NAME HAS CHANGED, LIST PREVIOUS NAME
DATE OF BIRTH
IF NAME HAS CHANGED, LIST PREVIOUS NAME
Phone Number & Email Address:
MUST INDICATE RIGHTS OF SURVIVORSHIP (CHECK ONE BELOW) IF NO BOX IS CHECKED “JOINT TENTANTS” WILL BE SELECTED
4B
Tenants by the Entirety
Joint Tenants
Tenants In Common
Partners (business)
TOD (Transfer on Death)
NAME OF LIENHOLDER
DATE OF BIRTH
NAME OF PERSON/COMPANY VEHICLE ACQUIRED FROM
DATE PURCHASED
(If individual)
5A
5B
MAILING ADDRESS - STREET, CITY, STATE, ZIP CODE
ADDRESS OF PERSON/COMPANY VEHICLE ACQUIRED FROM
IF NO LOAN,
CHECK BOX
DATE OF LOAN
IS THERE A SECOND
SIGNATURE OF PERSON/COMPANY (
) VEHICLE ACQUIRED FROM
DEALER NUMBER
VT LICENSE NO
AGENT
LOAN? IF YES, CHECK
BOX & SEND DETAILS
DO NOT SEND CASH
6A
6B
9
PURCHASE PRICE
TO CLAIM TAX CREDIT, COMPLETE SECTION 6B
DO NOT WRITE IN SHADED AREA
PURCHASER OF OLD VEHICLE
See instructions
PURCHASE PRICE
$
Registration
1
for fees
CITY
STATE
ON (DATE)
TAX CREDIT
$
Tax
2
YEAR
MAKE
PLATE
TAX EXEMPT #
$31.00 +
See instructions
NET TAXABLE COST
$
Title
3
$9.00 per loan
for fees
VIN
$22.00
TAX (6%)
$
Transfer
4
(ATV $10)
Please check here if vehicle was registered/titled out-of-state in your Spouse’s or Party to a Civil Union’s name only & is now being registered or titled in Your
Warranty Fee
$5.00
12
NEW Vehicles Only
or Party a Civil Union name only, and you were married to each other or were Party to a Civil Union when the tax was paid out-of-state
(j)
7
VERIFICATION OF VEHICLE IDENTIFICATION NUMBER - APPLICANT SHOULD NOT WRITE IN THIS SECTION
Fuel User
31
VEHICLE IDENTIFICATION (SERIAL) NUMBER. NO ALTERATIONS OR ERASURES ACCEPTED
STATE OF REG
Priority Handling
$2.25
5
DATE
AT TOWN OR CITY
STATE
Other
AUTHORIZED SIGNATURE
ORGANIZATION
Total Fees
Rater #
RF
NCIC
VINASSIST
CERTIFICATE NUMBER
PHONE NUMBER
MILEAGE (NO TENTHS)
Return #
MILES
Y
N
Y
N
KM
HOURS
The owner certifies that this vehicle 1) is properly equipped and in good mechanical condition; 2) was placed into use on or
As the applicant for registration of a commercial motor vehicle, which is a motor vehicle with a gross vehicle weight rating
before the date this application was signed; 3) currently has liability insurance in effect as required by 23 V.S.A. §800 (a). If
of 10,001 lbs. or more; is a vehicle that is used to transport hazardous materials; or is a vehicle that is designed to
8
transfer of plates, the owner and/or this vehicle are not under suspension pursuant to 23 V,S,A, §3009 (b) [diesel tax related].
transport 16 or more passengers, including the driver, I hereby declare that I have knowledge of the Federal Motor Carrier
Statements and warrants herein are certified under penalty of 23 V.S.A. §202, §203, §2082, and 32 V.S.A. §§ 8901-8915.
Safety Regulations, Title 49 of the Code of Federal Regulations, as adopted by the State of Vermont.
SIGNATURE (OWNER/LESSEE)
DATE
SIGNATURE (CO-OWNER/LESSOR)
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