Form Tr-211 - Custom Plate Order And Lost, Stolen, Replacement, Exchange Plate &/or Decal Application

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CUSTOM PLATE ORDER
KANSAS
AND
DEPARTMENT OF REVENUE
LOST, STOLEN, REPLACEMENT, EXCHANGE
DIVISION OF VEHICLE
PLATE &/or DECAL APPLICATION
Topeka, Kansas 66626-0001
County Number
County Name
Application Date
T
T
RANSACTION
YPE
(Check All that Apply)
Lost Plate
Stolen Plate
Replacement Plate
Special Plate App
Disabled Parking Placard
Lost Decal
Stolen Decal
Replacement Decal
Special Plate Exchange
Special Interest Collector’s Number
Current Vehicle Type
Current Registration Type
Current Plate No.
Current Decal No.
Registration Expiration Date
O
’
N
WNER
S
AME
(Last, First, Middle Initial)
Relationship
Street
City
State
Zip
V
I
EHICLE
NFORMATION
Year
Make
VIN
Model
Style
Gross Weight
Truck Class
L
/ S
/ R
/ E
I
OST
TOLEN
EPLACEMENT
XCHANGE
NFORMATION
Reason:
New: Plate No.
Decal No.
Vehicle Type
Registration Type
S
P
A
:
PECIAL
LATE
PPLICATION
st
nd
rd
th
Choices: 1
2
3
4
ARO/FCC No.
Special Interest No.
Disabled Person's Name
Address
City
State
Zip
è
Disabled Parking Placard
Type:
Permanent
Temporary
Expiration Date of Original Temporary Placard
INSURANCE
FEE SUMMARY
Company Name
Personalized Plate Fee
$
Policy Number
Decal Fee
$
I hereby certify that I am a resident or have a bona fide place of business
Reflectorized Plate Fee
$
in this county and that I am an owner of and have in effect financial
security for the aforementioned vehicle as required by law. I further
Replacement Plate Fee
$
certify that the information in this application is true and correct to the
County Service Fee
$
best of my knowledge and belief.
County Miscellaneous
$
FALSE
CERTIFICATION
CAN
RESULT
IN
CRIMINAL
PROSECUTION
TOTAL
$
Owner's Signature(s)
Completed application is to be submitted to your
County Treasurer’s Motor Vehicle Office.
Date
TR-211www (7-07)
Original to DMV, Copy to Treasurer and Owner

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