Sd Eform 0864 V5 - Application For Motor Vehicle Title & Registration

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SD EForm - 0864
V5
State of South Dakota
DATE
Application for Motor Vehicle Title & Registration
I
II
This application is for (Check Only One)
p Transfer p Out of State p Abandoned
TO BE COMPLETED BY COUNTY OFFICIAL
p New
p Interstate
p Operation by law
RMI
Registration Issue Date
Reg. Yr.
Reg. Co. No.
SD Title No.
p Repossession
Plate Type
South Dakota License No.
Decal No.
Plate Type
South Dakota License No.
Decal No.
III
1-4 Owner’s lessor’s Name: (Last, First, Middle) ; Description of type of ownership (and, or, DBA, WROS, Guardianship, lessee, lessor, etc.) ; Identification number (SD Dr. Lic. Or SS No.)
1.
Owner/Lessor & Lessee
Type of ownership
SD Driver’s License no. or Social Security no.
2.
Owner/Lessor & Lessee
Type of ownership
SD Driver’s License no. or Social Security no.
3.
Owner/Lessor & Lessee
Type of ownership
SD Driver’s License no. or Social Security no.
4.
Owner/Lessor & Lessee
Type of ownership
SD Driver’s License no. or Social Security no.
Title
_________________________________________________________________________________________________________________________________________________
Co. No.
ADDRESS
CITY
STATE
ZIP + 4
IV
.
PRIMARY VIN or SERIAL NO
MAKE
MODEL
BODY TYPE
VEH. CODE
YEAR
WEIGHT/CC
COLOR
FUEL
PREVIOUS STATE/TITLE BRAND
MAKE
YEAR
SECONDARY VIN or SERIAL NO.
ODOMETER
ODOMETER INDICATOR:
Condition
TONNAGE
(Check One)
(Check if Applicable)
1.
ACTUAL MILEAGE
¨
X-Junking Certif.
2.
EXCEEDS ODOMETER’S
COMPLETE FOR VEHICLES 9
MECHANICAL LIMITS
¨
YEARS OLD OR NEWER
B-Rebuilt
3.
NOT ACTUAL MILEAGE
Dealer Price Certification: I hereby certify that the purchase price and trade-in allowance in item V of the application is correct, and that all accessories and added equipment have been reported.
Dealer Name and Number
Signature of Dealer or Dealer’s Agent
MOTOR VEHICLE PURCHASER’S CERTIFICATE
Purchased from___________________________________________________________________
Name
NOTE: A guide published by the automobile industry will be used to check values.
Address
City
State
Zip
V
1. Purchase Price (see reverse side) ……………………...……..$_________________
Bill of Sale Not Available______Computer NADA’ED _____
2. Less Trade-In Allowance ……………………….……………….$_________________
Vehicle Traded-In
0.00
3. Difference …………………………………..……………………$_________________
0.00
Year
Make
Serial Number
S.D. Title No.
4. Tax 3% of Line 3 …………………………………………………$_________________
IMPORTANT: Original title will be mailed to the owner unless otherwise
5. Credit for Tax Paid to Another State ...………………………...$_________________
indicated.
6. Title Fee and Penalty Fee …………………….…..……………$_________________
p Mail to Lienholder
p Mail to Owner
CHECK ONE:
7. License Fee …………………………………….………..………$_________________
st
1
Lienholder _________________________________________________________
8. Solid Waste Fee …………………………….….……………..…$_________________
Mailing Address _______________________________________________________
9. County Wheel Tax (if applicable) ………….…...………………$_________________
City ___________________________________________State
_____ Zip _________
10. Other Fees……………………………………….……………...$_________________
0.00
11. Balance Due ………………………………………....…………$_________________
nd
2
Lienholder _________________________________________________________
Penalty:
.
Any person failing to pay the full amount of excise tax is subject to a Class 1 misdemeanor
¨
Mailing Address _______________________________________________________
TAX EXEMPT (If claiming exemption, list exemption # from Section VI on back of form.)
¨
Rental Vehicle/SD Sales Tax # _____________________________________________________
¨
City __________________________________________State
_____Zip __________
Title Only (note: If applying for a “Title Only” in signing this application, you are attesting that the
vehicle will not be used upon the streets and highways of this state or any state.
Note any additional liens in section IX on reverse side.
The application, under the penalties of law and as rightful owner of the
vehicle described on this application, declares that the information set
forth on this application is true and correct.
X____________________________________ / _________ /_________
Signature
Date
APPLICATION MUST BE DATED WHEN SIGNED.
If vehicle is co-owned, all owners must sign. If vehicle is
X___________________________________ / _________ / _________
Signature
Date
company owned, company name and title of authorized
agent signing the application must be noted.
PENALTY: Any person who intentionally falsifies information on this application is guilty of a class 6 Felony.
MV-608-(5/99)

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