Free 44049.FH11 - Indiana

APPLICATION FOR CERTIFICATE OF TITLE
State Form 44049 (R4 / 3-02)

l STATE Approved by State Board of Accounts 2002

OF INDIANA

l

BUREAU OF MOTOR VEHICLES

TO BE COMPLETED BY A POLICE OFFICER, BMV OFFICIAL OR BMV CERTIFIED DEALER SIGNEE FOR OUT OF STATE TITLES. I HEREBY CERTIFY THAT I PERSONALLY EXAMINED THE FOLLOWING VEHICLE AND FIND THE IDENTIFICATION NUMBER TO BE AS FOLLOWS.

VEHICLE IDENTIFICATION NUMBER
11 13 17

I/WE THE UNDERSIGNED SWEAR OR AFFIRM THAT THE INFORMATION ENTERED ON THIS FORM IS CORRECT. I/WE UNDERSTAND THAT MAKING A FALSE STATEMENT ON THIS FORM MAY CONSTITUTE THE CRIME OF PERJURY. FUTHERMORE, I/WE AGREE TO INDEMNIFY AND HOLD HARMLESS THE INDIANA BMV FROM ANY LIABILITY ARISING FROM THIS TRANSACTION. X __________________________________________________________ X __________________________________________________________ DATE: ______________________________________________________

YR.

MAKE

MODEL

TYPE

DATE

INSPECTOR'S PRINTED NAME & TITLE

CITY

INSPECTOR'S SIGNATURE

BADGE, BRANCH OR DEALER PLATE NO. BRANCH NO. INVOICE NO.

The law requires that you apply for Certificate of Title within thirty-one days from the date of purchase of a motor vehicle. There is a delinquent fee for failure to do so. Attach Certificate of Title assigned by seller. On endorsed Titles, liens must be released. Supporting documents surrendered with this application cannot be returned to the applicant. *In accordance with Federal Code 383.

1.

TITLE NUMBER

BMV USE ONLY

2.

*SOC. SEC./FEDERAL I.D.NO.

APPLICANT'S NAME

BMV USE ONLY

3.

STREET ADDRESS

CITY

STATE

ZIP CODE

4.

VEHICLE I.D. NUMBER

VEH.YEAR

VEH. MAKE

VEH. MODEL NO. VEH TYPE

ODOMETER

5.

FORMER TITLE NUMBER

PURCHASE DATE

LIEN

SPEED

PICK UP

MAIL

DEALER NO.

BMV USE ONLY

6.

FIRST LIEN'S NAME OR SPECIAL MAILING ADDRESS

STREET ADDRESS

7.

CITY

STATE

ZIP CODE

BMV USE ONLY

8.

SECOND LIEN'S NAME

STREET ADDRESS

9.

CITY

STATE

ZIP CODE

LICENSE NUMBER

LICENSE FORMS YEAR USED

BMV USE ONLY

GROSS RETAIL & USE TAX AFFIDAVIT - I/WE HEREBY CERTIFY THAT SALES OR USE TAX ON THIS VEHICLE WAS PAID AS INDICATED BELOW.
10. SELLING PRICE LESS TRADE-IN * AMOUNT SUBJECT TO TAX AMOUNT OF TAX DEALER BRANCH EXEMPT

$

$

$

$

IF EXEMPT PLACE PARA.#

*Your Social Security number / Federal I.D. number is being requested by this agency under IC 4-1-8-1. Disclosure is manadatory and this document cannot be processed without it.

APPLICANT RESPONSIBLE FOR ACCURACY OF INFORMATION APPLICATION FOR CERTIFICATE OF TITLE
l

STATE OF INDIANA

l

BUREAU OF MOTOR VEHICLES

BUREAU - TO BE MAILED WITH TITLE REPORT