Motor Vehicles Services And Or County Tag Agent Title
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100
r Original Title Fee
r County Ad Valorem Tax
$18.00
$______________ . __
MV-1 (Rev 5/02)
00
r Replacement Title Fee
r License Tag Fee
8.00
$______________ . __
00
r Title Penalty Fee
r Mfg. Fee. Special Tag
10.00
$______________ . __
00
Motor Vehicles Services
r Expedited Title Fee
r Special Tag Fee
10.00
$______________ . __
00
And/or County Tag Agent
r Tag Trans fer Fee
License Plate to Transfer ____________________
$______________ . __
00
r 10% Tax Penalty
(Attach copy of current registration)
$______________ . __
Title / Tag Application
($5 Minimum)
00
r 25% Tag Penalty
$______________ . __
00
r $1.00 Tag/Decal Mail Fee
Current License Plate _______________________
$______________ . __
Vehicle Section
Vehicle Identification Number
Year
Make
Body Style
Series Model
Color
Cylinders
Fuel Type
New or Used
Date Purchased
Emission Certificate
Insurance Company
Insurance Policy Number
Prev. Title Number
Previous
District
Number
State
Ga. County of Residence
Odometer Reading
Odometer Reading is Actual Miles Unless One of the Following is Checked
Exceeds Mechanical Limits of Odometer
Not the Actual Mileage, Warning Odometer Discrepancy
EXEMPT
Complete For All Trucks over 14,000 Gross Vehicle Weight
Gross Vehicle Weight & Load
Straight Truck?
Used For Hire?
Type of Trailer Pulled?
Product Hauled?
Is This A Farm Vehicle?
N
N
N
Yes
o
Yes
o
Yes
o
_____
Owner Section
1
Number of owners
Leased Vehicle
NO
Yes
Complete Lessee Section
Owner # 1
Full Legal Name of Owner 1
Date Of Birth
First,
Middle,
Last
Suffix
.
Ga. Drivers License No
(If Individual)
Name of Business / Name of Leasing Company
Owner # 2
Full Legal Name of Owner 2
Date Of Birth
.
Ga. Drivers License No
(If Individual)
First,
Middle,
Last
Suffix
Owner Addres s (Residence or Business)
Mailing Address (If Different from Residence or Business)
Seller Section
Lessee Section
Ga. Dealer or Bank’s 12 digit Identification Number:
Ga. DL Number of Lessee (if individual)
Name and Address
Date Of Birth of Lessee (if individual)
Lessee’s legal name and Addr. or Business Lessee Name and Addr:
Sellers County Name, If Ga. seller
Lessee’s County Name
Security Interests or Liens Section
1
Number of Security Interests or Liens: __
001102014923
Security Interest / Lienholder 1 Identification Number:
Security Interest / Lienholder 2 Identification Number:
Name and Address
Name and Address
PLATINUM FEDERAL CREDIT UNION
751 DEKALB INDUSTRIAL WAY
DECATUR, GA 30033
Security Interest / Lienholder 3 Identification Number:
Security Interest / Lienholder 4 Identification Number:
Name and Address
Name and Address
I do solemnly swear under criminal penalty of a felony for fraudulent use of a false or fictitious name or address or for making a material false
statement punishable by fine up to $5000 or by imprisonment of up to 5 years, or both, that the statements contained here in are true and accurate.
Owner # 1 Signature ________________________________________________________________________________________________
Owner # 2 Signature _________________________________________________________________________________________________
Applications (except signatures) must be typed, printed legibly in black or blue ink or electronically
completed and printed.
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