Mississippi Motor Title Application (Page 2 of 2) in pdf

DATE

RETURN

RCVD.

FOR OFFICE USE

RCVD. _________ CASH $_________

DATE__________

DATE _________

CCK$________________ CCK#________________________________

MO$________________ MO#________________________________

MISSISSIPPI BOAT TITLE APPLICATION

Department of Wildlife, Fisheries, and Parks

BOAT REGISTRATION #

TITLE #

Boat Registration

MI –

1505 Eastover Drive

Jackson, MS 39211-6374

DATE OF ISSUE

PROCESSED BY:

601-432-2055

CHECK THE APPLICABLE BOXES

1. New MS Boat Title

$12.70

4. Corrected Title Only

$12.70

2. Transfer MS Title

$12.70

TOTAL AMOUNT REMITTED

If requesting a duplicate please furnish information concerning the original

3. Duplicate Title

$12.70

certificate and the circumstances of its loss, theft, mutilation or destruction.

MAKE CHECK OR MONEY ORDER PAYABLE TO MISSISSIPPI DEPT. OF WILDLIFE, FISHERIES, AND PARKS

LAST

FIRST

MIDDLE

DATE OF BIRTH

SOCIAL SECURITY NUMBER

APPLICANT’S

NAME (PRINT)

STREET OR POST OFFICE BOX NUMBER

HOME TELEPHONE NUMBER

MAILING

ADDRESS

CITY

STATE

ZIP

COUNTY

U.S. CITIZEN?

WORK TELEPHONE NUMBER

YES

E-MAIL ADDRESS

LAST

FIRST

MIDDLE

DATE OF BIRTH

SOCIAL SECURITY NUMBER

A CO-OWNER

(IF APPLICABLE)

DESCRIPTION OF BOAT

MODEL YEAR

VALUE OF BOAT

HULL IDENTIFICATION NUMBER

MAKE

LENGTH

F T

BOAT IS SUBJECT TO THE FOLLOWING LIENS

FIRST LIEN

BOAT

ADDRESS

CITY, STATE, ZIP

TELEPHONE

NAME AND ADDRESS OF PERSON FROM WHOM

BOAT WAS PURCHASED

DATE OF LIEN

$ AMOUNT OF LIEN

I CERTIFY THAT I OWN THE ABOVE BOAT AND UNDERSTAND AND AGREE THAT AN EXAMINATION MAY BE MADE OF THE BOAT BY THE

STATE OF MISSISSIPPI, DEPARTMENT OF WILDLIFE, FISHERIES AND PARKS.

STATE OF ______________________________________ Appeared before me _______________________________________________, who first being duly SWORN

says that of his or her own personal knowledge all the information given and STATEMENTS made on the application are true and correct and that the

described is

watercraft

subject to no liens or encumbrances except as noted on the application.

THIS THE ______________________________________________ DAY OF ___________________________________________________, 20______

APPLICANT’S SIGNATURE

DRIVERS LICENSE NO.

NOTARY’S SIGNATURE

MY COMMISSION EXPIRES

CO-OWNER’S SIGNATURE

DRIVERS LICENSE NO.

DEALER’S SIGNATURE

DEALER PERMIT NUMBER

Mississippi Code Section 97-7-10 states (in Part).... “Whoever makes or uses any false, fictitious, or fraudulent statement or entry, shall, upon conviction be punished by a fine of

not more than $10,000.00 or by imprisonment for not more than 5 years, or by both such fine and imprisonment.”

REV. 12/09

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Mississippi Motor Title Application Page 2

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