Title And Registration Manual Application Template
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1Staple Attachments HERE
KANSAS
TITLE AND REGISTRATION
PRIORITY
DEPARTMENT OF REVENUE
MANUAL APPLICATION
DIVISION OF VEHICLE
County Name
County No.
County Situs
Application Date
TRANSACTION TYPE:
*VEHICLE TYPE:
REGISTRATION TYPE:
* Code for: Salvage/Rebuilt Salvage:
Nonhighway/Formerly Nonhighway:
Plate Number
Decal Number
Legal Type
Reg. Expires
Tax Unit
Class Code
ACQUISITION CODE:
OWNER’S NAME(S)
Relationship Code
(Last, First, Middle Initial)
Address
City
State
ZIP
VIN:
Year:
Make:
Model:
Style:
ø
Purchase/Brought into KS Date:
Mileage:
.
Actual
Exceeds
Not Actual
Exempt
Empty Wght.:
Gross Wght.:
Truck Class:
Local Base Point:
New Gross Wght. & Truck Class:
Registration Mileage:
(<Use on truck/trailer wght. change)
SPECIAL MAIL OUT
Temporary
Permanent
Lienholder
(Mail just the title.)
(Mail title & renewal notice.)
(Mail title to lienholder.)
Name:
Address
City
State
ZIP
st
nd
1
Lienholder’s
2
Lienholder’s
Name
Name
Address, City
Address, City
State, ZIP
State, ZIP
st
nd
1
TOD
2
TOD
T
Name
Name
O
Address, City
Address, City
D
State, ZIP
State, ZIP
PLATE TRANSFER INFORMATION
FEE SUMMARY
Title Fee............................................
Previous Vehicle’s VIN:
Penalty .........................................
Year:
Make:
Style:
Registration Fee ................................
Vehicle Sold to/Repossessed by:
Penalty .........................................
ADDING NAME(s) Relationship:
Parent
Spouse
Child
Decal Fee ..........................................
Signature of Person(s)
.........................................
Being Added:
Reflectorized Plate Fee .....................
Total.............................................
Insurance Policy No.:
Property/Tax Due..............................
Insurance Co. Name:
Penalty .........................................
I hereby certify that I am a resident or have a bona fide place of business in this county and that
Previous Prop./RV Tax Due ........
I am an owner of and have in effect financial security for the aforementioned vehicle as required
by Kansas law. I further certify that all liens and/or encumbrances, if any, are listed and the
Prev. Prop./RV Tax Penalty.........
information on this application is true and correct to the best of my knowledge and belief.
Total.............................................
FALSE CERTIFICATION CAN RESULT IN CRIMINAL PROSECUTION
Sales Tax...........................................
Owner’s Signature(s)
County Miscellaneous Fee................
GRAND TOTAL ..............................
Date
TR-212a www. (04/02)
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