Application For Kentucky Certificate Of Title/registration Form - Hardin County Clerk Page 3
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1
2
3APPLICATION MUST BE COMPLETED IN BLUE OR BLACK INK
TC 96-182 Rev. 1/2000
COMMONWEALTH OF KENTUCKY
APPLICATION FOR KENTUCKY CERTIFICATE OF TITLE/REGISTRATION
Check the type of application desired
Duplicate
Other
Title Only
Transfer
First Time
Salvage
If Duplicate is checked, the original Certificate Title is:
Lost
Destroyed
Damaged
Illegible
Other
Vehicle Identification Section
CERTIFIED INSPECTOR SECTION
I, (Certified Inspector)
Of
County
Phone No. (
)
VIN
Make
Do certify under penalties that I have physically inspected the vehicle described herein
and that the supporting documents are consistent with the vehicle description.
Body Style
Model
Model No.
Color
Year
THE VEHICLE HAS AN ODOMETER READING OF
NO TENTHS
THE VEHICLE IDENTIFICATION NUMBER IS:
Motor No.
Cylinders
Truck Weight
(If motorcycle)
INSPECTION
TITLE BRAND DISCLOSURE
REQUESTED BY
Check appropriate block if:
Rebuilt Vehicle
Water Damage
OWNER DRIVER LICENSE NO. & STATE
When block is checked and title does not include brand, provide
jurisdiction
and title number
CERTIFIED INSPECTOR’S SIGNATURE
INSPECTOR NO.
DATE
where previous brand was issued.
ODOMETER DISCLOSURE ****CAUTION READ CAREFULLY BEFORE YOU CHECK A BLOCK****
Federal law requires that you state the mileage upon transfer of ownership. Failure to complete or providing a false statement may results in fines and/or imprisonments.
I certify to the best of my knowledge that the odometer reading is the actual mileage of the vehicle unless one of the following statements is checked.
1.
(no tenths)
The mileage stated is in excess of its mechanical limits.
Odometer Reading
WARNING -- ODOMETER DISCREPANCY
2.
The odometer reading is not the actual mileage.
TOTAL CONSIDERATION AND TRADE-IN INFORMATION
Giving a false statement as to the total consideration paid is a Class D Felony with a minimum fine of $2,000.
Trade In $
Net Cost $
Tax $
Sale Price $
(Credit allowed only on vehicles registered in KY and applicant has paid tax.)
Make
Year
VIN No.
Title No.
Trade In
Date of Sale
Make
Year
VIN No.
Title No.
Seller and buyer further certify subject to penalaties of forgery in the second degree, that each has supplied true and correct information to the best of his knowledge and belief, in this document, including the above
affadivit.
LEFT BLANK INTENTIONALLY
JOINT OWNERSHIP:
OR
AND
NOTE: If neither block is checked the Title Transfer will require both signatures
DEALER NO.
SS#
BIRTH MO.
NAME OF SELLER
NAME OF OWNER/BUYER
STREET ADDRESS
PHONE NO.
NAME OF OWNER/BUYER
SS#
BIRTH MO.
CITY
COUNTY
STATE
ZIP
ADDRESS
CITY
STATE
ZIP
COUNTY
I (
have)(
have not) applied for a loan in connection with the vehicle described therein and if not, I (
will)(
will not) apply for a loan within 30 days of this application.
LESSEE NAME OR OTHER
FIRST LIENHOLDER
LESSEE ADDRESS
ADDRESS
COUNTY
ZIP
CITY
STATE
COUNTY LIEN TO BE FILED IN
<-------SIGN HERE
SELLER’S SIGNATURE
OWNER/BUYER(S) SIGNATURE(S)
SELLER’S SIGNATURE
OWNER/BUYER(S) SIGNATURE(S)
Date of Transfer
<---NOTARY HERE
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
COUNTY CLERK USE ONLY
TYPE APPLICATION
DATE OF ISSUANCE
TITLE NO.
PLATE NO.
I certify under above described penalty that I have reviewed this application and the documents supporting it and that the same are present and consistent with this application; that I received the applicaation on the
date and time indicated hereon and that fees were collected as indicated. I further certify that the required information has been entered into the automated vehicle identifiation system (AVIS)
COUNTY
DATE
SIGNATURE & TITLE OF ISSUER
I certify that the lien indicated to be filed has been noted into the automated system and that a title will be withheld for 30 days, or until financing statement and fees required are received,
whichever occurs first.
SIGNATURE
DATE
DO NOT ACCEPT TITLE SHOWING ANY ERASURES, ALTERATION, OR MUTILATIONS. MUST BE COMPLETED IN BLUE OR BLACK INK.
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