Form Tc 96-182 - Application For Kentucky Certificate Of Registration

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Kentucky Transportation Cabinet

TC 96‐182

Division of Motor Vehicle Licensing

10/2015

APPLICATION FOR KENTUCKY CERTIFICATE OF TITLE OR REGISTRATION

Check the type of application desired ___________________________

Duplicate

Title Only

Transfer

First Time

Salvage

Classic

If Duplicate is checked, the original Certificate of Title is: ____________

Lost

Destroyed

Damaged

Illegible

Other

Vehicle Identification Section

CERTIFIED INSPECTOR SECTION

I, (Certified Inspector – Print Name)

VIN

Make

County, Phone No.

do certify under the penalty provisions of KRS 186A.115(4)(d) that I have physically

inspected the vehicle described herein to be roadworthy and that the supporting documents

Year

Body Style

Model

Model No.

Color

are consistent with the vehicle description.

THE VEHICLE HAS AN ODOMETER READING OF

NO TENTHS

Motor No.

Cylinders

Truck Weight

THE VEHICLE IDENTIFICATION NUMBER IS:

(if motorcycle)

TITLE BRAND DISCLOSURE

INSPECTION REQUESTED

Check appropriate block if:

Rebuilt Vehicle

Water Damage

If block is checked and title does not include brand, provide

jurisdiction

and title number

previous brand was

OWNER DRIVER LICENSE NO. & STATE

issued.

________________________________________________________________________

CERTIFIED INSPECTOR’S SIGNATURE

INSPECTOR NO.

DATE

ODOMETER DISCLOSURE ****CAUTION READ CAREFULLY BEFORE YOU CHECK A BLOCK****

49 USC Sec. 32705 and KRS 190.300 require that you state the mileage upon transfer of ownership. Failure to complete or providing a false statement may result in fines and

or imprisonment. I certify to the best of my knowledge that the odometer reading is the actual mileage of the vehicle unless one of the following statements is checked.

(no tenths)

1. The mileage stated is in excess of its mechanical limits.

Odometer Reading

2. The odometer reading is not the actual mileage. WARNING – ODOMETER DISCREPANCY.

TOTAL CONSIDERATION AND TRADE-IN INFORMATION

Sale Price $

Trade In $

Net Cost $

Tax $

Make

Year

Title No.

VIN No

Date of Sale

Make

Year

VIN No.

Title No

Seller and buyer certify pursuant to the penalty provisions of KRS 190.990(5),that each has supplied true and correct total consideration information to the best of their knowledge and belief in this document, including the above affidavit.

JOINT OWNERSHIP:

AND

NOTE: If neither box is checked the Title Transfer shall require both signatures

NAME OF SELLER

DEALER NO.

NAME OF OWNER/BUYER

S.S.#, KyDL#, or Govt. issued #

BIRTH MO.

STREET ADDRESS

PHONE NO.

NAME OF OWNER/BUYER

S.S.#, KyDL#, or Govt. issued #

BIRTH MO.

CITY

COUNTY

STATE

ZIP

STREET ADDRESS

PHONE NO.

EMAIL ADDRESS

CITY

COUNTY

STATE

ZIP

EMAIL ADDRESS

I (

have) (

have not) applied for a loan in connection with the vehicle described herein and if not, I (

will) (

will not) apply for a loan within 30 days of this application.

LESSEE NAME OR OTHER

FIRST LIENHOLDER

LESSEE ADDRESS

ADDRESS

CITY

COUNTY

STATE

ZIP

COUNTY LIEN TO BE FILED IN

SELLER’S SIGNATURE

OWNER/BUYER(S) SIGNATURE(S)

SELLER’S SIGNATURE

DATE OF TRANSFER

OWNER/BUYER(S) SIGNATURE(S)

_________________________________________________________

________________________________________________________

Attesting Official

Title

Attesting Official

Title

_______

_______________

_____

_______

_____________

_____

Subscribed and attested before me this

day of

Subscribed and attested before me this

day of

___________________________________________

__________________________________________

My commission expires

COUNTY CLERK USE ONLY

TYPE APPLICATION

DATE OF ISSUANCE

TITLE NO.

PLATE NO.

I certify subject to the penalty provisions of KRS 190.990(5) that I have reviewed this application and the documents supporting it and that the same are present and consistent with this application; that I received the application on the date and

time indicated hereon and that fees were collected as indicated. I further certify that the required information has been entered into the automated vehicle identification system (AVIS).

__________________________________________________________________________________________________________________________________________________________________________________________________

SIGNATURE & TITLE OF ISSUER

COUNTY

DATE

I certify that the lien indicated to be filed has been noted into the automated system and that a title will be withheld for 30 days, or until financing statement and fees required are received, whichever occurs first.

Signature _______________________________________________

Date _________________

DO NOT ACCEPT TITLE SHOWING ANY ERASURES, ALTERATION, OR MUTILATIONS. MUST BE COMPLETED IN BLUE OR BLACK INK IF NOT COMPLETED ON-LINE.