Form Tr-156 - Complaint Of Lien Holder'S Failure To Comply With Lien Release Requirements Page 2

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CONTACT INFORMATION

Have you had any contact with the lien holder since the payment and request was sent?

Yes

If yes: Contact was by

Phone

Mail

Fax

E-mail

Form < Please attach a copy.

If by Phone:

Name of Person Who

Made the Contact/Call:

Phone Number Used

Date of

To Make the Contact:

the Contact

Name of Person

Contacted/Spoken With:

Below, provide the substance of the conversation, and any follow up action you or the lien holder may have taken as a

result of this contact. Please include as much detail as possible. Attach additional pages as needed.

Have you received the release of lien, or title if applicable, as of the date of this complaint?

Yes

If yes, date received

If available, please include a photocopy of any correspondence or forms you sent to the lien holder with the original payment and a copy of the

original form of payment (check) if not paid electronically. In addition, attach copies of the documents listed in the Contact Information portion of this

form which was sent to or received from the lien holder, and a copy of the release of lien or title if it has been received.

I certify that all information contained in this complaint form is true and correct to the best of my knowledge.

Signature of Person Filing Complaint

Printed Name of Person Who Signed to the Left

Date

Please attach all available copies and/or forms mentioned in this complaint to this completed and signed form

and mail to:

Kansas Department of Revenue

Division of Vehicles

915 SW Harrison

Topeka, Kansas 66626-0001

Attention: T & R-Lien Holder Complaint