Form Tc 96-184 - Motor Boat Transaction Record Application For Title/registration
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1
2TC 96-184
Kentucky Transportation Cabinet
04/2010
Division of Motor Vehicle Licensing
Page 1 of 2
MOTOR BOAT TRANSACTION RECORD APPLICATION FOR
TITLE/REGISTRATION
KRS 186A states that:
Any person who knowingly enters or attests to the entry
ORIGINAL – Transportation
COPY – Clerk
COPY - Buyer
of false or erroneous information upon this form will be
subject to the penalties of forgery in the second degree.
PLEASE NOTE: The original of this form must be completed in blue or black ink.
SELLER SECTION
OWNER-BUYER SECTION
____________________________________________________________
________________________________
NAME OF SELLER OR TRANSFEROR
DATE OF BIRTH
________________________________________________________
____________________________________________________________
NAME OF OWNER OR BUYER
SSN. OR FED. I.D.
NAME OF CO-OWNER
________________________________________________________
____________________________________________________________
NAME OF CO-OWNER OR BUYER
SSN. OR FED. I.D.
STREET ADDRESS
________________________________________________________
____________________________________________________________
STREET ADDRESS
PHONE NUMBER
CITY
STATE
ZIP
COUNTY
MOTORBOAT IDENTIFICATION SECTION
(See reverse
________________________________________________________
CITY
STATE
ZIP
COUNTY
of copy for codes)
________________________________________________________
____________________________________________________________
CITIZENSHIP OF APPLICANT
SEX
KY NO.
BOAT TYPE
HULL IDENTIFICATION
__________________________
________________________
____________________________________________________________
DEALER NUMBER
COUNTY OF DOCKAGE
YEAR
MAKE
MODEL
I have
have not applied for a loan in connection with the motorboat described
____________________________________________________________
herein and if not,
I will
not apply for a loan within 30 days of this application.
LENGTH
BEAM
HULL MATERIAL
PROPULSION
________________________________________________________
____________________________________________________________
st
1
LIENHOLDER
FUEL
CAPACITY
USE
________________________________________________________
____________________________________________________________
ADDRESS
NO. TOILETS
TYPE
APPROVED
________________________________________________________
ND
2
LIENHOLDER
____________________________________________________________
PURCHASE YEAR
PURCHASE AMOUNT
________________________________________________________
ADDRESS
____________________________________________________________
MOTOR MAKE
YEAR
H.P.
# MOTORS
_____
I HEREBY APPLY FOR (REGISTRATION)
REGISTRATION AND/OR A
CERTIFICATE OF TITLE. I CERTIFY THAT THE DESCRIBED MOTORBOAT
____________________________________________________________
WILL BE OPERATED CONSISTENT WITH THE CLASSIFICATION
MOTOR SERIAL NUMBER
PURCHASE YEAR
PURCHASE AMOUNT
REQUESTED ABOVE, AND THE MARINE SANITATION DEVICE FOR THE
TOILET IS PROPERLY OPERATING AND PROPERLY USED FOR THE
I WARRANT THAT THE MOTORBOAT DESCRIBED ABOVE IS NOT SUBJECT TO
WATER BODY WHERE THE MOTORBOAT IS KEPT OR OPERATED. I
AN UNTERMINATED LIEN AND THAT NO LOAN IN CONNECTION WITH THIS
FURTHER CERTIFY UNDER THE PENALTY DESCRIBED ABOVE, THAT I
MOTORBOAT HAS NOR WILL BE APPLIED FOR BY SELLER WITHIN 30 DAYS OF
HAVE SUPPLIED TRUE AND CORRECT INFORMATION TO THE BEST OF
THIS APPLICATION. I HEREBY CERTIFY THAT THE FOREGOING INFORMATION
MY KNOWLEDGE AND BELIEF.
IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF.
________________________________________________________
____________________________________________________________
OWNER BUYER SIGNATURE
TITLE
SELLER’S SIGNATURE
TITLE
________________________________________________________
____________________________________________________________
________________________________________________________
ATTESTING OFFICIAL
TITLE
____________________________________________________________
ATTESTING OFFICIAL
TITLE
SUBSCRIBED AND SWORN TO BEFORE ME THIS ________ DAY OF
____________________ 20 _______
________
SUBSCRIBED AND SWORN TO BEFORE ME THIS
DAY OF
_______________
________
20
MY COMMISSION EXPIRES ________________________________________
_______________________________________
MY COMMISSION EXPIRES
HAS THE APPLICANT BEEN PREVIOUSLY LICENSED OR REGISTERED AS AN OWNER?
CLERK SECTION
IF SO, WHEN AND BY WHAT STATE OR COUNTY?
HAS THE APPLICANTS LICENSE REGISTRATION OR CERTIFICATE NUMBER BEEN
TYPE APPLICATION
CONTROL NO.
DECAL #
CANCELLED, SUSPENDED, REVOKED, OR REFUSED?
IF SO, GIVE DATE AND REASON.
CLERK’S ID
CLERK’S FEE
REG. EXPIRES
DATE OF ISSUANCE
STATE FEE
DVR USE
RECEIPT
VERIFICATION
VERIFICATION
ONLY
CLERK SIGNATURE
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