Form Mvt-21-1 - Request For Assignment And Transfer Of Lien - Alabama Department Of Revenue

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ALABAMA DEPARTMENT OF REVENUE
APPLICATION
TO RECORD A
MVT-21-1
TRANSFER OF A
MOTOR VEHICLE DIVISION – TITLE SECTION
LIEN WITH AN
P. O. BOX 327640
R 6/04
OUTSTANDING
MONTGOMERY, AL 36132-7640
ALABAMA TITLE
NOT TO BE USED ON
A TRANSFER OF
OWNERSHIP
TITLE NUMBER
THIS FORM MAY BE DUPLICATED OR ADDITIONAL COPIES MAY BE OBTAINED FROM THE DEPARTMENT WEB SITE AT
REQUEST FOR ASSIGNMENT AND TRANSFER OF LIEN
VEHICLE INFORMATION
VEHICLE IDENTIFICATION NUMBER
TRANS
YEAR
MAKE
MODEL
BODY TYPE
CURRENT ALABAMA TITLE NO.
CODE
MODEL
04
CYLS
NEW
USED
DEMO
DATE OF PURCHASE (M/D/Y)
NUMBER
COLOR
ODOMETER READING
DEPARTMENT USE ONLY
LIENS
OWNER INFORMATION
NAME (LAST, FIRST, MIDDLE)
FELONY OFFENSE FOR FALSE ADDRESS
FOR OFFICE USE ONLY
MAILING ADDRESS
CITY
STATE
ZIP
NAME
ALABAMA OPERATOR (LESSEE) NAME AND / OR RESIDENT ADDRESS IF DIFFERENT FROM ABOVE
RESIDENT ADDRESS
FELONY OFFENSE FOR FALSE ADDRESS
CITY
STATE
ZIP
LIEN INFORMATION
NAME FIRST LIENHOLDER
FELONY OFFENSE FOR FAILURE TO NAME LIENHOLDER WITH INTENT TO DEFRAUD
MAILING ADDRESS
LIEN DATE (M/D/Y)
LOCATOR NO.:
CITY
STATE
ZIP
REJECT TO:
NAME SECOND LIENHOLDER
FELONY OFFENSE FOR FAILURE TO NAME LIENHOLDER WITH INTENT TO DEFRAUD
REASONS:
MAILING ADDRESS
LIEN DATE (M/D/Y)
EXAMINER NO.:
CITY
STATE
ZIP
ENCL.:
SIGN COMPLETED FORM ONLY, FELONY OFFENSE FOR FALSE STATEMENTS
The undersigned assignor and assignee confirm that the lien held by the assignor has been transferred to the assignee. Both parties hereby request
that a new certificate of title be issued subject to the liens listed on this application.
Assignor
Assignee
Lienholder
Lienholder
Name ______________________________________________________
Name _____________________________________________________
Address ____________________________________________________
Address ___________________________________________________
City/State/Zip ________________________________________________
City/State/Zip _______________________________________________
Authorized Signature __________________________________________
Authorized Signature _________________________________________
Printed Name ________________________________________________
Printed Name _______________________________________________
Date _______________________________________________________
Date _______________________________________________________
Note: Lien date for transferred lien(s) must remain the same. Also, no changes are permitted in the owner information (other than address changes).
HANDWRITTEN APPLICATIONS WILL NOT BE ACCEPTED
THIS FORM MAY BE DUPLICATED
Submit $15.00 Application Fee (non-refundable) in
Handwritten Applications
FEE – $15.00
certified funds payable to Alabama Department of
Will Not Be Accepted!
Revenue. Do not send personal checks or cash.

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