Application For Certificate Of Title And/or Registration

Download a blank fillable Application For Certificate Of Title And/or Registration in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Application For Certificate Of Title And/or Registration with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

APPLICATION FOR CERTIFICATE OF TITLE AND/OR REGISTRATION

D# or R# _______________

Regular Title

Salvage Title

Applying For:

Registration Month _____________

(Dealer or Recycler Number)

Form 411007 (06-06)

OWNER INFORMATION

Present to: The County Treasurer of your residence; The County Treasurer of the primary user if nonresident owned; The County Treasurer of residence or of the primary user if owned by a firm, association, or corporation.

Owner #1

Iowa DL # or Iowa ID # or Social Security #

:____________________________________________________________________________________

:________________________________________________

First Name

Middle Name

Last Name

(If individual)

Ownership Status:

AND

Birth Date

Federal Employer Identification #

:________________________________

:__________________________________________________________

(Check One)

(If individual)

(If organization)

Bona fide Residence Address of Owner #1

:________________________________________________________________________________________________________________________________________________________

Address

City

County

State

Zip Code

Mailing Address of Owner #1

:_____________________________________________________________________________________________________________________________________________________________________

Address

City

County

State

Zip Code

Owner #2

Iowa DL # or Iowa ID # or Social Security #

:____________________________________________________________________________________

:________________________________________________

First Name

Middle Name

Last Name

(If individual)

Birth Date

Federal Employer Identification #

:________________________________

:__________________________________________________________

(If individual)

(If organization)

Bona fide Residence Address of Owner #2

:________________________________________________________________________________________________________________________________________________________

Address

City

County

State

Zip Code

Mailing Address of Owner #2

:_____________________________________________________________________________________________________________________________________________________________________

Address

City

County

State

Zip Code

Owner #3

Iowa DL # or Iowa ID # or Social Security #

:____________________________________________________________________________________

:________________________________________________

First Name

Middle Name

Last Name

(If individual)

Birth Date

Federal Employer Identification #

:________________________________

:__________________________________________________________

(If individual)

(If organization)

Bona fide Residence Address of Owner #3

:________________________________________________________________________________________________________________________________________________________

Address

City

County

State

Zip Code

Mailing Address of Owner #3

:_____________________________________________________________________________________________________________________________________________________________________

Address

City

County

State

Zip Code

PRIMARY USER INFORMATION (Complete only if the vehicle is owned by a non-resident or by a firm, association, or corporation)

Primary User #1

Iowa DL # or Iowa ID #

:____________________________________________________________________________________

:____________________________________________________________________

First Name

Middle Name

Last Name

(If individual)

Birth Date

Federal Employer Identification #

:________________________________

:__________________________________________________________

(If individual)

(If organization)

Bona fide Residence Address of Primary User #1

:__________________________________________________________________________________________________________________________________________________

Address

City

County

State

Zip Code

Mailing Address of Primary User #1

:_______________________________________________________________________________________________________________________________________________________________

Address

City

County

State

Zip Code

Primary User #2

Iowa DL # or Iowa ID #

:____________________________________________________________________________________

:____________________________________________________________________

First Name

Middle Name

Last Name

(If individual)

Birth Date

Federal Employer Identification #

:________________________________

:__________________________________________________________

(If individual)

(If organization)

Bona fide Residence Address of Primary User #2

:__________________________________________________________________________________________________________________________________________________

Address

City

County

State

Zip Code

Mailing Address of Primary User #2

:______________________________________________________________________________________________________________________________________________________________

Address

City

County

State

Zip Code

VEHICLE INFORMATION

VIN________________________________________________________Year______________Make__________________________Model_______________________Type(car, truck,etc)_______________Style___________Color_________

Fuel____________ Cylinders________Tonnage___________GVWR______________Sq.Footage______________Iowa Plate Number (If applicable)____________Validation Number__________________________Validation Year__________

Purchase Date or Date Brought Into State__________________VIN of traded vehicle (if applicable)_______________________________________________________Trailer Empty Weight (If applicable)

Over 2000lbs

2000lbs or less

SECURITY INTEREST INFORMATION

Give complete statement of security interests (liens). If none, so state:______________________

Nature

Held By

Address (Street, City, State, Zip Code)

First Security

Interest

Federal Employer Identification # or Social Security #:

Second Security

Interest

Federal Employer Identification # or Social Security #:

Third Security

Interest

Federal Employer Identification # or Social Security #:

PURCHASE PRICE

Taxable Purchase Price

$______________________

(Purchase price less any trade)

THE FOLLOWING FOR DEALER USE ONLY:

The vehicle dealer named below as “seller” does hereby certify that the new

vehicle described above was sold to the applicant for the following consideration which includes freight, manufacturer’s tax,

(Check only if applicable)

accessories, and other added equipment or services and represents the total delivered price to the purchaser, valued in

I claim exemption from payment of Iowa Use Tax. List Exemption Code________________

money whether received in money or otherwise

(See Page 2)

Sale Price.....................................................................$________________

Date Registration Applied For Card Issued

I/We certify under penalty of perjury that the foregoing is true and correct*

Less Trade-In ...............................................................$________________

If none, so state:____________________

X_________________________________________________________________________________________

Signature of Owner #1

Date

Less Non-Taxable Charges (specify) ..........................$________________

Registration Fee Collected:____________

Less Rebate applied to purchase price of the vehicle .$________________

X_________________________________________________________________________________________

Equals Tax Price ..........................................................$________________

Signature of Owner #2

Date

I/We certify under penalty of perjury that the foregoing is true and correct.

X_________________________________________________________________________________________

_____________________________________________________________________________________________

Signature of Owner #3

Date

Dealer No.

Dealership Name

By_______________________________________________________________________

By___________________________________________________________________________________________

If Firm, Association, Corporation, or Attorney in Fact

Authorized Representative & Title

Important

: Be certain that dates and other information given are correct. Any person who uses a false or fictitious

name, makes a false statement or otherwise commits a fraud upon this application is punishable by prison sentence and

possible fine. This application also constitutes an application for refund of excess credit, when applicable.

Yes, I would like to make a voluntary contribution to the anatomical gift public awareness and transplantation fund in the amount of $ _________________________