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<br /> P RT 2. T D LER A531GNMLNT ANb A F T E ER T TO BUY i 5�:OAY TE OF
<br /> Applicant's legalNome(first,nt�dle; astJ or Firtn Name(Lessor,T►u8t): �DLi]CI �C .RPID[J F�JN���p� Tebpha+ei�lumtier
<br /> MaibngAddress City State Zip County !
<br /> �
<br /> CaApplicenPs Lepal Name(flrst,middla,last)or Firtn Name(Lessor,Trust): DL CID CORPID�FEIN(�hedc tk+e� Tsiephone Number
<br /> MaiUng Address C� Zp �u�
<br /> Chedc one: Date ot Sefe Sell(ng Prfce
<br /> ❑ � ❑ And ❑ And/Joint Tenar�te with RIgM of SurvNorahip
<br /> t)domete�.Com,ete lf vehide Is lesa than ten(1D)ysare oid. ,
<br /> 1 certity�he�ineLer reatiing is the actual v'shide mfleage unlecs one of the foflowing stetemants is checked.
<br /> ❑ Mileage stated ia in excess of its mechanical limits. � Odometer reading ia not the actual itiileape wamin�`odometw�scteper►cy).
<br /> Name of Deskr Dealer Lbense Number Sigrtqtuia of BuyarlTra�steree Dabe(Mk+:,Dey,Year)
<br /> X X ,
<br /> Sfgnadue olAutitO►iud/lpent Date(Mo.,Day,Yearj Signaturo ot Buyer/irens�eree 08te(Mo.,pay,Yaar)
<br /> X X :
<br /> Hand-Prfnted Name of Authorfzed Agent Daytime Telephone Number Hand-Printed Name(s)of Buyer(syTrensferee(s)
<br /> PARr 2A SECOND 1?�AI:ER ASSIGNMENT ANO W RRAN OF TiTLE ELNER:•7 E TO 6U HIN ib DAYS OM D TE OF S
<br /> AppficanYs t.Qga1 Name{first,middte;last)or Firm Name(Lessor,Tivet): Dt Q CIDQ GORPID FEIN iC�edc a+e)Te
<br /> IeP}►one Numkier
<br /> Malpng Address Cfty State Zip C,ounty
<br /> Co-ApplicanYs Legai Name(flrs2,middle,last)or Firm Name(Lessor,Truat): 0 DL CID CORPID FEIN(�necic one) Telephone Number
<br /> Ma ing Address CRy te Zip . a��y
<br /> Check one: � Or � And ❑ AndJJoint Tenants with RIgM of Survtvorship ��e�Sate Selling P�ce
<br /> Odometer.Co�1 ete if vehide i6 Iess th8t►ten(10j years Old.
<br /> i cerUy 1he o�fometer teadirlg is the actuet vefiwle mfleage unless one of the following statements is checked.
<br /> Q MUsege statetl is ifl.eXoess of fts mechenkal Bmits: Qdometer reading is not the actual mileage(warning•odometer discrepancy).
<br /> Name of Dealer Dealer License Number Signature of Buyer/Trensteree Dete(Mo„Dray,Year)
<br /> X x
<br /> �, Signature of Authorized AgeM Date(Mo.,Oay,Year) Signeture of BuyedTransferee Oate(Mo.,Oay,Year)
<br /> X X
<br /> HahdPrinted Name of Aufhotized qgent Daytime Telephone NUmber Hand-Printed Name(s)of Huyetis}�Rarulerne(s)
<br /> PART 3. 6U R S /TRANSFE EE S CEfMIFICATION AND ApPUCATION PRESENT 7d DEP/IRTIYlEN7 OF TRANSPORT/ItION-WITt�N 30�AYS
<br /> MOTOR VE#i1CLE EXCiSE TAX EXENIPTtONS(Fste�exemption number,lf appBcable} �
<br /> (1)�ilt I�aT y�e,husband,pnn�nt,child,broMer,or sh,aer(Circie One)
<br /> (2)JduN IenpncY wilh ripM of wrnvorship and now YeML^'e is being put In ona name on1Y (14)��sabled�Ari�eriean Vo}�n or��wr Pnsonor M.War�-Lettar ot EI �b1G1 hpm VA
<br /> (3)InlntrF.nrtce �Q Y
<br /> (<lC (�5)Na�prnMienturemsein'w ' N�vsdedperao�n'cor�wrayqn.mw�edhuses
<br /> �3e�^a��1'�rt�age,adoAtion;a courl order 1Uiocle One) (18)Mob{N
<br /> (5)vehlpe a uk++tl _ Ui c h'��i�sa+s P��y specl�
<br /> cq fh�4uphakaaepurcM1aseey�memenllCkdeUne) (1B) tarned bf+«lV�eilvblddti
<br /> A, If hur wes � TM°�Y P�G+enhiv w cwpa+tion(Gre�e onal ome'kxined ,
<br /> B- N wx was�on Ihe tatal lease eans�fer�iw�.t�x k dw ao the lease b out emou�. (1B)Dissalved paAneqhlp amryqaLon{Cirde One)Date Nucc�vedd
<br /> p�id ori ths fWi purchaae daf y�llrava besn fn p�sussion of lhe vehicle (20)Picbd�l or prems r�on-{poft scllool bue6s
<br /> over one yeer,tfo ta%�Crdue (2�i 7�8neter inte tarttUy Tnpt:.Revb�ayle or Irravoesble[��de�ne)
<br /> C�. !(hx wa9 pe�d on ltie hdl.purehace prica a+M yoV have baen In possesaion of tlie vehicle (23y M�tary nome tepotd-m�py ar d�a�a�a r��rcle One) �.
<br /> for lesa than qhaytar,t�x.is due on+he�aa.v b�yout arnount (?A)Mob�e Fiome(SFN 90p1 isquirs�
<br /> (7� Lien cM1ange-RECORD OpOMETER READMfG {2S)Nprdi pak"p�ppWqq�s�ibdhqslp� I
<br /> (8}IMerslate cartlars-Account Number (2�Repossesebn(SFN 2880 requked) . I
<br /> (11)Dealer reaale•USED vehkle �` (28)Insurence company-total loss eetdement
<br /> (13)Tribal(SFN 18085 teq�)' (Zb)Olher 15peuy 1
<br /> Futl Purchase Price � F'ust Lienholder(title wi0 be mailed to first lienholder)
<br /> Less Trade-In AUowance g
<br /> Maping Address
<br /> Less Total Loss Allowance $
<br /> DfRerence/Subtotal , �
<br /> Tax(690�of Difference/Subtotal) � C�� State Zip
<br /> TiNe Fee (55.00) � Sece�d lienholder
<br /> license Fee $
<br /> License Plate Credk Amount g Mai6ng Addcass
<br /> Piafe Trensfer Fee ($5.00) $ Ci�y State Zip
<br /> TOTAL FEES DUE: $
<br /> Year and Make of Trade-In The Guyer(appitcan�,subjoof to the penalBes of tsw;eetdfies the purchase prige of the
<br /> vehkle. The buyer makes epplfcation for certfficate of title to the veh(cle,having
<br /> VIN of Ttede-I� ecquked It subject to the liens stated. The buyer cettlfles the vehicle is and will
<br /> wntinue to be insured while erel' u n ic itreets and h'.fiWg'a
<br /> � NOTE:A guide published by the automobik induatry wi�l ba used to eheek vatues; Signature of BUyeNTransfeiee Date(Mo.,Day,Year)
<br /> PENAL7Y Persons making a false entry or.�ttering a govemment '
<br /> document are guiity of a class A misdemeanor. siflna�,re or euyerrrra�srerea o�e�nno.,oay,Year)
<br /> sFN za7s�ev,o�-zot�) �
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