Fillable Authorization Letter printable pdf download

Authorization Letter

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IKE

ULLIVAN

Tax Assessor-Collector

Authorization Letter

I, We,

do hereby authorize the following representative:

(Enter as listed on DBA)

Title Service phone:

to complete the transaction(s) indicated below.

Please initial one or more:

Purchase Registration (Please Circle)

 Vehicle driven with Expired Registration- Yes or No

 Ticket/Citation issued- Yes or No

Replacement Plates (if needed)

Duplicate Receipt

Change address to:

_______________________________________________________________________________________________

Other:

All of the above:

Customer, Dealer or Company Appointing Motor Vehicle Title Service

Name:

Dealer #:

Phone:

Address:

City:

State:

Zip:

Effective Date:

(Please note expiration date is one year after the effective date.)

For the following described vehicle: (for individual transactions only)

Year:

Make:

Body Style:

Vehicle Information Number:

Signature of Authorized Person and/or Registered Owner

Date

Home: (

)

Work: (

)

Copy owner’s valid state-issued Driver’s License or Federal Identification (example-U.S. Passport, U. S. Naturalization Card)

If registered owner and/or seller of the vehicle is in a company and/or an automobile dealer name please attach business

card, along with copy of valid state-issued Driver’s License or Federal Identification (example - U. S. Naturalization Card,

U.S. Passport).

Disclosure: This form is used for the sole purpose to complete the above described transactions and may not be used in lieu

of prescribed form VTR-271 (Power of Attorney to Transfer Motor Vehicle). Falsifying information on any required

statement or government document is a criminal offense and is punishable by fine and/or imprisonment.

TS-466

Rev. 2/15 v2

Authorization Letter

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