Application For Duplicate Certificate Of Title

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DEPARTMENT OF SAFETY
DIVISION OF MOTOR VEHICLES
Richard C. Bailey, Jr.
BUREAU OF TITLE AND ANTI-THEFT
Director of Motor Vehicles
23 Hazen Drive, Concord, NH 03305
J.
John
Barthelmes
TDD Access:
Relay NH 1-800-735-2964
Commissioner
of Saf~ty
APPLICATION FOR DUPLICATE CERTIFICATE OF TITLE
I hereby make application, in accordance with the New Hampshire laws for the issuance of a duplicate certificate of title to the below described vehicle. The
original certificate has been (check one).
NEVER RECEIVED [J
LOST[J
DESTROYED[J
2. DATE(S)OF BIRTH
1. OWNER'S NAME(S)(LAST,FIRST,MIDDLE)
MO/DAYNR
PER APPLICATION
$25.00
A.
(MUST GIVE CURRENT MAILING ADDRESS) STREET OR BOX NO.
MAKE CHECK PAYABLE TO:
B.
STATE OF NH - DMV
DO NOT TYPE IN THIS SPACE
ZIP CODE
STATE
CITY OR TOWN
3. LEGAL RESIDENCE IF OTHER THAN MAILINGADDRESS
APPROVED BY
SUSPENDED BY
5. ODOMETER-ACTUALMILEAGE
4. VEHICLE IDENTIFICATIONNUMBER
17.
IS'
9. VEHICLECOLOR(S)
6. MAKE OF VEHICLE
MODELNAME OR NUMBER
BODYTYPE
r6.
15. PREVIOUSTITLE NO.
STATE
10.YR.OFMFG.\11.MODELYR.
112. NO. OF CYLINDERS \ 13. GROSSWEIGHT 114.AXLES
THIS VEHICLE IS SUBJECT TO THE FOLLOWING LIENS:
MOTORVEHICLE
17.
FIRST LIEN HOLDER'S
NAME (IF NONE, TYPE NONE)
USE ONLY
ADDRESS
ZIP CODE
STATE
CITY OR TOWN
18. SECOND LIEN HOLDER'S NAME & ADDRESS
-1
DMV DOES NOT FORWARD MAIL, PLEASE VERIFY ALL ADDRESSES
OWNER'S SIGNATURE(S):
20.
DATE SIGNED (MO/DAYIYR)
READ PENALTY BELOW BEFORE SIGNING
19.
OWNER'S SIGNATURE(S)
OR LIENHOLDER
X
X
19
IF THE OWNER IS A CORPORATION,
PARTNERSHIP
OR OTHER ASSOCIATION,
THE PERSON SIGNING IN BOX
MUST CERTIFY BELOW, UNDER PENALTY OF
PERJURY,
THAT HE/SHE IS AUTHORIZED
TO SIGN ON BEHALF OF THE OWNER.
HEREBY CERTIFY THAT I AM AN AGENT AUTHORIZED
TO SIGN THIS APPLICATION
ON BEHALF
I,
PRINT NAME
, THE OWNER NAMED IN BOX 1
OF
AUTHORIZATION
FOR MAILING TO LICENSE DEALER:
I!WE HEREBY CERTIFY THAT I!WE INTEND TO TRANSFER MY/OUR INTEREST IN THE ABOVE VEHICLE TO A LICENSED DEALER.
I!WE AUTHORIZE
THE DIVISION OF
MOTOR VEHICLES TO FORWARD THE N.H. CERTIFICATE
OF TITLE ISSUED AS A RESULT OF THIS APPLICATION
TO THE DEALER NAMED BELOW (SEE REVERSE
SIDE "INSTRUCTIONS"
#5).
#:
21. DEALER'S
NAME:
I ADDRESS:
DLR
I
X
IX
PENALTY:
A PERSON WHO, WITH FRAUDULENT
INTENT, USES A FALSE OR FICTITIOUS
NAME OR ADDRESS,
OR MAKES A MATERIAL
FALSE STATEMENT,
OR FAILS TO
DISCLOSE
A SECURITY
INTEREST,
OR CONCEALS
ANY OTHER MATERIAL
FACT, IN AN APPLICATION
FOR A CERTIFICATE
OF TITLE, OR IN ANY PROOF OR
STATEMENT
IN WRITING IN CONNECTION
THEREWITH,
SHALL BE GUILTY OF A CLASS B FELONY IF A NATURAL PERSON, OR GUILTY OF A FELONY IF ANY OTHER
PERSON, RSA 262:1,1.
#4
IF LIENHOLDER WAS NAMED ON ORIGINAL TITLE, SEE REVERSE SIDE "INSTRUCTIONS"
'---l

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