Form Rmv-1 - Vehicle Registration Form

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Massachusetts Department of Transportation
3. Number of Documents______
r
r
RO (Registration Only)
RX (Registration Transfer)
RMV-1 Application Form
r
r
r
4.
ST (Salvage Title)
RT (Registration & Title)
TAR (Title Add Registration)
r
r
r
TO (Title Only)
SW (Summer/Winter Swap)
SS (Surviving Spouse)
1.
2.
REG. EFF . DATE
REG. EXP . DATE
5. Plate Type
6. Registration Number
7. Previous Title #
8. State
Registration/Vehicle
Registration/Vehicle
9. Type of Registration:
10. Vehicle Identification Number:
q
q
q
q
q
Passenger
Bus
Taxi
Livery
Commercial
q
q
q
q
q
Trailer
Auto Home
Semi-Trailer
Motorcycle
Other ________________
11. Year
12. Make
13. Model Name
14. Model #
15. Body Style
16. Circle Color(s) of Vehicle
0-Orange 1-Black 2-Blue 17. # of Cylinders/Passengers/Doors/Wheels
3-Brown 4-Red 5-Yellow 6-Green 7-White 8-Gray 9-Purple
/
/
/
q
q
q
q
q
q
Gasoline
18. Transmission 19. Total Gross Weight (Laden)
20. Motor Power
21. Bus:
Regular
DTE
Livery
Taxi
School Pupil
q
q
q
q
Automatic
Diesel
Propane
Electric
If carrying passengers for hire, max no of passengers that can be seated: ________
q
q
q
Other ___________
q
q
Manual
Hybrid
Yes
No
If school bus, is it used exclusively for city, town, or school district?
24. EIN/FID # (see block 29)
22.
Owner # 1 License # / ID # / or SSN
23.
Owner # 2 License # / ID # / or SSN
If Sole Proprietor
Owner
provide SSN in #22
25. Owner # 1 Name (Last, First, Middle)
25b. Sex
26. Owner # 1 Date of Birth
25a. Height
MALE
FEMALE
_____ Ft _____ In
27. Owner # 2 Name (Last, First, Middle)
27a. Height
27b. Sex
28. Owner # 2 Date of Birth
_____ Ft _____ In
MALE
FEMALE
29. Corp/Co/Organization Name (see block 24)
30. City/Town Where Vehicle is Principally Garaged:
31. Mailing Address
City
State
Zip Code
32.
Residential or Corp/Co/Organization Address (see block 24 and 29)
City
State
Zip Code
33A. Lessee’s MA License Number or EIN/FID Number. If out-of-state Lessee, use SSN and date of birth.
33B. Lessee’s Name:
M
M
D
D
Y
Y
Sales or Use Tax Schedule
34. Lessee’s Address, City, State, and Zip Code
56 A. SALE BY LICENSED MOTOR VEHICLE DEALER
35. Date of Purchase
36. Odometer Reading
Title
MA DOR-Registered Dealer EIN/FID # ______________________
Total Sale Price
$ ______________________
q
q
q
q
37.
New Vehicle
38. Title Type:
Clear
Salvage
Reconstructed
(adjusted for dealer’s discount and manufacturer’s rebate)
q
q
q
q
Used Vehicle
Owner Retained
Theft
Prior Owner Retained
Less Manufacturer’s Excise
$ ______________________
39. Primary Salvage Title Brands:
40. Secondary Salvage Brand(s)
q
q
Repairable
Parts Only
Net Sales Price
$ ______________________
Lienholder
41. Date of 1st Lien
42. Date of 2nd Lien
Less Trade-in Allowance For:
$ ______________________
I/we certify that all liens on this vehicle are listed below
43. First Lienholder Code
44. Name
Yr __________
Make_____________ Model_______________
Trade-in VIN ___________________________________________
45. Lienholder’s Address
Taxable Sales Price
$ ______________________
6.25% Sales Tax
$ ______________________
46. Second Lienholder Code
47. Name
B. SALES BY OTHER THAN MOTOR VEHICLE DEALER
48. Lienholder’s Address
Gross Sales Price (Proof Required)
$ ______________________
6.25% Sales/Use Tax
$ ______________________
Insurance Certification
The company signatory hereto hereby certifies that it has or will insure or guarantee performance by the applicant
hereinbefore named with respect to the motor vehicle hereinbefore described for a period at least coterminous with
C. CLAIM EXEMPTION FROM TAX CODE: __________________
that of such registration under a motor vehicle liability policy, binder or bond which conforms to the provisions of general laws, Chapter 175, Section 113A, and that the premium
charge and classification on the effective date of registration are as established by the commissioner of insurance under Chapter 175, Section 113B, 113H and Chapter 175E.
Form Attached (if required)
49A. Policy Effective Date:
_____________________
Exempt Organization Certificate #__________________________
49A.
Policy Change Date:
_____________________
Fee Info.
49B. Manual Class:
49C. Ins. Company & Code:
57. Reg:
$ ___________________
Payment:
Insurance Co’s Authorized Representative’s Signature (Original Only)
I/We the applicants hereby certify under the penalties of perjury that there are no outstanding excise tax liabilities on the vehicle
q
Signatures
Title:
$ ___________________
Cash
described above that have been incurred by the applicant(s), any member of the applicant’s immediate family who is a member of
q
Tax:
$ ___________________
Check
the applicant’s household or the business partner of the applicant(s). I/We hereby further certify that all information contained in this application is true
and correct to the best of my knowledge and belief. I/We understand that false statements are punishable by fine, imprisonment or both.
q
P&I:
$ ___________________
EFT/ CC
50. Signature of Owner From Block 25 or 29. If owner is listed in Block 29, signer must also print name.
Total:
$ ___________________
Clerk ID:
51. Signature of 2nd Owner From Block 27.
58. Batch No:
52. Authorized Dealer’s Signature
53. Dealer Reg. No.
59. Clerk/End User Initials:
54. Seller’s Name (Please Print)
55. Seller’s Address
Progressive Ins. form approved 1/2013
This form approved by the RMV 1/2013

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