Form Vr-005 - Application For Certificate Of Title

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Motor Vehicle Administration

VR-005 (06-13)

6601 Ritchie Highway, N.E.

Glen Burnie, Maryland 21062

APPLICATION FOR CERTIFICATE OF TITLE

READ INSTRUCTIONS ON REVERSE SIDE

APPLICANT’S FIRST NAME

MIDDLE

LAST

CO-APPLICANT’S FIRST NAME

MIDDLE

LAST

APPLICANT’S SOUNDEX/MARYLAND DRIVER’S LICENSE NO.

DATE OF BIRTH

CO-APPLICANT’S SOUNDEX/MARYLAND DRIVER’S LICENSE NO. / FEIN #

DATE OF BIRTH

MONTH

DAY

YEAR

MONTH

DAY

YEAR

APPLICANT’S STREET ADDRESS

CITY OR TOWN

CO-APPLICANT’S STREET ADDRESS

CITY OR TOWN

COUNTY

STATE

ZIP CODE

EMAIL ADDRESS

COUNTY

STATE

ZIP CODE

EMAIL ADDRESS

IS THE VEHICLE TO BE TITLED AS JOINT TENANTS OR TENANTS BY ENTIRETIES?

JOINT TENANTS

TENANTS BY ENTIRETIES

VEHICLE DESCRIPTION

MODEL YEAR

MAKE OF VEHICLE

MODEL NO.

BODY STYLE

VEHICLE IDENTIFICATION NUMBER

NEW VEHICLE

USED VEHICLE

MAKE OF VEHICLE

# OF CYLINDERS

MOTOR CARRIER #

UNIT #

MODEL YEAR

TYPE OF FUEL

TWO STAGE VEHICLE

COMPLETE MAKE & YEAR

FOR EACH VEHICLE

TRUCK

TRUCK TRACTOR

BUS

MOTORCYCLE

TRAILER (SPECIFY LENGTH)

ENGINE NO.

ENGINE SIZE (C.C.)

G.V.W.

TYPE OF TRAILER

G.V.W.

G.C.W.

AXLES

SEATS

If this vehicle is subject to any liens or encumbrances, complete the following section(s). Attach form VR-217 for additional Lien Filings.

LIEN FILING FEE $20.00 for each Lien filed. IF NOT SUBJECT TO A LIEN, WRITE THE WORD “NONE” BELOW.

NAME OF SECURED PARTY

STREET ADDRESS OF SECURED PARTY

KIND OF LIEN (DESCRIBE)

DATE OF LIEN

AMOUNT OF LIEN

ACCOUNT NUMBER

CITY OR TOWN

STATE

ZIP CODE

PURCHASE INFORMATION FOR TAX PURPOSES – SEE INFORMATION ON REVERSE SIDE

IF VEHICLE RECENTLY PURCHASED

MARYLAND DEALER’S CERTIFICATION

DEALERS ONLY

MD. EXCISE

I hereby certify, under penalty of perjury, that the purchase price represents the full

CERTIFIED

amount paid for this vehicle.

SELLING PRICE

Date of Delivery

TRADE-IN ALLOWANCE

TAX 6% OF

$_______________________

DEALER’S NUMBER

N U

FULL PURCHASE PRICE

TAXABLE PRICE

NAME OF DEALERSHIP

ATTACH A NOTARIZED BILL OF SALE SIGNED BY

GROSS TAX COLLECTED

SELLER(S) AND PURCHASER(S)

SIGNATURE OF DEALER

DATE

COLL. FEE .6% OF GROSS OR $12 MAX. FEE ALLOW.

VIN OF TRADE-IN _______________________________________________ _________________________ STATE ___________________________________________

NET TAX REMITTED

Complete this section in its entirety if you qualify for an Excise Tax Credit in this State. I/we have been resident(s) in Maryland for approximately __________________.

I/we last registered this vehicle in _________________________ and paid ___________% tax (if no tax paid, write “NONE”)

Check here if active duty military.

APPLICATION FOR NEW REGISTRATION PLATES OR TRANSFER OF REGISTRATION PLATES

I/we do hereby make application for:

New Tags

Transfer of Tags

Title Only

Is your motor vehicle now suspended or revoked in this or any

other state?

Yes

Is this vehicle to be operated for short term rental?

Yes

If transferring plates, complete below:

TAG NO. __________________________________ and STICKER NO. ___________________________ The vehicle to which these plates were affixed has been sold,

traded or otherwise transferred to: Name ______________________________________________________________________________________________________________

Address ___________________________________________________________________________________________________________________________________________

Name of Insurance Co. ______________________________________________________________________ Policy or Binder No. _____________________________________

Agent or broker _____________________________________________________________________________ Class of Tags desired ____________________________________

Federal and State law requires that you state the mileage in connection with this vehicle. Failure to complete or providing a false statement may result in

fines and/or imprisonment.

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:

The mileage stated is in excess of its mechanical limits.

ODOMETER READING _____________________ (NO TENTHS)

The odometer reading is not the actual mileage. WARNING – ODOMETER DISCREPANCY.

I/we certify that I/we have compared the manufacturer’s vehicle identification number on this application with the number on the vehicle and they agree and that this vehicle is subject to the liens or

encumbrances indicated herein and none other. For vehicles registered over 10,000 lbs. by signing this application, I/we certify knowledge of the Federal and State Motor Carrier Safety Laws and

certify this vehicle is maintained in compliance with the Maryland Preventive Maintenance Program. If making application for new plates or transfer of registration plates I/we certify under Penalty of

Law that the vehicle is covered by at least the minimum amounts of insurance required by the Maryland Motor Vehicle Laws, and further certify that this vehicle will be continuously insured throughout

its registration period. I/We further certify under Penalty of Perjury that the statements made herein are true and correct to the best of my knowledge, information and belief.

Signature of Applicant __________________________________________________________ Printed Name of Applicant _____________________________________

Signature of Co-Applicant ______________________________________________________ Printed Name of Co-Applicant __________________________________

Witness my/our Hand(s) and Seal(s) this ______________ day of ________________ year _______________________

Signature of Co-Signer _________________________________________________________ Relationship __________________________________________________

Soundex ______________________________________________________________________ Date of Birth __________________________________________________

For more information, please call: 410-768-7000 (to speak with a customer agent).

TTY for the hearing impaired: 1-800-492-4575. Visit our website at: