TC 96-182

KentuckyTransportationCabinet
TC96182
10/2015
DivisionofMotorVehicleLicensing
APPLICATIONFORKENTUCKYCERTIFICATEOFTITLEORREGISTRATION
Check the type of application desired ___________________________
Duplicate
Title Only
Transfer
If Duplicate is checked, the original Certificate of Title is: ____________
Lost
Destroyed
Damaged
First Time
Illegible
Salvage
Classic
Other
CERTIFIED INSPECTOR SECTION
Vehicle Identification Section
I, (Certified Inspector Print Name)

VIN
of
Make
County, Phone No.
do certify under the penalty provisions of KRS 186A.115(4)(d) that I have physically
inspected the vehicle described herein to be roadworthy and that the supporting documents
Year
Body Style
Model
Model No.
Color
are consistent with the vehicle description.

THE VEHICLE HAS AN ODOMETER READING OF
Motor No.
Cylinders
(if motorcycle)
TITLE BRAND DISCLOSURE
Check appropriate block if:
Truck Weight
Rebuilt Vehicle
INSPECTION REQUESTED
Water Damage
If block is checked and title does not include brand, provide

jurisdiction
BY
if previous brand was
and title number
NO TENTHS
THE VEHICLE IDENTIFICATION NUMBER IS:
OWNER DRIVER LICENSE NO. & STATE
issued.
________________________________________________________________________
CERTIFIED INSPECTORS SIGNATURE
INSPECTOR NO.
DATE
ODOMETER DISCLOSURE ****CAUTION READ CAREFULLY BEFORE YOU CHECK A BLOCK****

49 USC Sec. 32705 and KRS 190.300 require that you state the mileage upon transfer of ownership. Failure to complete or providing a false statement may result in fines and
or imprisonment. I certify to the best of my knowledge that the odometer reading is the actual mileage of the vehicle unless one of the following statements is checked.
(no tenths)
Odometer Reading
1. The mileage stated is in excess of its mechanical limits.

2. The odometer reading is not the actual mileage. WARNING ODOMETER DISCREPANCY.
TOTAL CONSIDERATION AND TRADE-IN INFORMATION
Sale Price $
Date of Sale
Trade In $
Net Cost $
Tax $
Make
Year
VIN No.
Title No.
Make
Year
VIN No.
Title No.
Seller and buyer certify pursuant to the penalty provisions of KRS 190.990(5),that each has supplied true and correct total consideration information to the best of their knowledge and belief in this document, including the above affidavit.
JOINT OWNERSHIP:
OR
AND
NOTE: If neither box is checked the Title Transfer shall require both signatures
NAME OF SELLER
DEALER NO.
NAME OF OWNER/BUYER
S.S.#, KyDL#, or Govt. issued #
BIRTH MO.
STREET ADDRESS
PHONE NO.
NAME OF OWNER/BUYER
S.S.#, KyDL#, or Govt. issued #
BIRTH MO.
CITY
COUNTY
STATE
ZIP
EMAIL ADDRESS
STREET ADDRESS
CITY
PHONE NO.
COUNTY
STATE
ZIP
EMAIL ADDRESS
I(
have) (
have not) applied for a loan in connection with the vehicle described herein and if not, I (
will) (
will not) apply for a loan within 30 days of this application.
LESSEE NAME OR OTHER
FIRST LIENHOLDER
LESSEE ADDRESS
ADDRESS
CITY
COUNTY
STATE
ZIP
SELLERS SIGNATURE
SELLERS SIGNATURE
COUNTY LIEN TO BE FILED IN

OWNER/BUYER(S) SIGNATURE(S)
DATE OF TRANSFER
OWNER/BUYER(S) SIGNATURE(S)
_________________________________________________________
________________________________________________________
Attesting Official
Title
Subscribed and attested before me this _______ day of _______________ 20 _____
Attesting Official
Title
Subscribed and attested before me this _______ day of _____________ 20 _____
My commission expires ___________________________________________
My commission expires __________________________________________
COUNTY CLERK USE ONLY

TYPE APPLICATION
DATE OF ISSUANCE
TITLE NO.
PLATE NO.
I certify subject to the penalty provisions of KRS 190.990(5) that I have reviewed this application and the documents supporting it and that the same are present and consistent with this application; that I received the application on the date and
time indicated hereon and that fees were collected as indicated. I further certify that the required information has been entered into the automated vehicle identification system (AVIS).
__________________________________________________________________________________________________________________________________________________________________________________________________
SIGNATURE & TITLE OF ISSUER
COUNTY
DATE
I certify that the lien indicated to be filed has been noted into the automated system and that a title will be withheld for 30 days, or until financing statement and fees required are received, whichever occurs first.
Signature _______________________________________________
Date _________________
DO NOT ACCEPT TITLE SHOWING ANY ERASURES, ALTERATION, OR MUTILATIONS. MUST BE COMPLETED IN BLUE OR BLACK INK IF NOT COMPLETED ON-LINE.

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KentuckyTransportationCabinet

If Duplicate is checked, the original Certificate of Title is: ____________

CERTIFIED INSPECTOR SECTION

Vehicle Identification Section

I, (Certified Inspector Print Name)

County, Phone No.

are consistent with the vehicle description.

If block is checked and title does not include brand, provide

if previous brand was

and title number

THE VEHICLE IDENTIFICATION NUMBER IS:

OWNER DRIVER LICENSE NO. & STATE

ODOMETER DISCLOSURE ****CAUTION READ CAREFULLY BEFORE YOU CHECK A BLOCK****

1. The mileage stated is in excess of its mechanical limits.

TOTAL CONSIDERATION AND TRADE-IN INFORMATION

S.S.#, KyDL#, or Govt. issued #

S.S.#, KyDL#, or Govt. issued #

will not) apply for a loan within 30 days of this application.

LESSEE NAME OR OTHER

COUNTY LIEN TO BE FILED IN

My commission expires ___________________________________________

My commission expires __________________________________________

COUNTY CLERK USE ONLY

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ODOMETER DISCLOSURE CAUTION READ CAREFULLY BEFORE YOU CHECK A BLOCK