Massachusetts Department of Transportation 3.

Number of Documents______ rRO (Registration Only) ✔RX (Registration Transfer)

r

ORIGINAL
RMV-1 Application Form 4. rST (Salvage Title) rRT (Registration & Title) rTAR (Title Add Registration)
www.massrmv.com
1. REG. EFF . DATE 2. REG. EXP . DATE rTO (Title Only) rSW (Summer/Winter Swap) rSS (Surviving Spouse)
5. Plate Type 6. Registration Number 7. Previous Title # 8. State
Registration/Vehicle PASS 4010348 13939139 NH
9. Type of Registration: ✔Passenger qBus qTaxi qLivery qCommercial 10. Vehicle Identification Number:
q
q Trailer q Auto Home q Semi-Trailer q Motorcycle q Other ________________
2HGFA16596H524365
11. Year 12. Make 13. Model Name 14. Model # 15. Body Style 16. Circle Color(s) of Vehicle 2-Blue 17. # of Cylinders/Passengers/Doors/Wheels
0-Orange 1-Black ●
2006 Honda Civic 4DSED 3-Brown 4-Red 5-Yellow 6-Green 7-White 8-Gray 9-Purple 4 / 4 / 4 / 4
18. Transmission 19. Total Gross Weight (Laden) 20. Motor Power ✔Gasoline
q 21. Bus: q Regular q DTE q Livery q Taxi q School Pupil
✔Automatic
q q Diesel q Propane q Electric If carrying passengers for hire, max no of passengers that can be seated: ________
q Manual q Hybrid q Other ___________ If school bus, is it used exclusively for city, town, or school district? q Yes q No
22. Owner # 1 License # / ID # / or SSN 23. Owner # 2 License # / ID # / or SSN 24. EIN/FID # (see block 29) If Sole Proprietor
Owner S11340092 provide SSN in #22

25. Owner # 1 Name (Last, First, Middle) 25a. Height 25b. Sex 26. Owner # 1 Date of Birth
_____
5 10
Ft _____ In ✔ MALE FEMALE
Smith, Eric David 05/04/1995
27. Owner # 2 Name (Last, First, Middle) 27a. Height 27b. Sex 28. Owner # 2 Date of Birth
_____ Ft _____ In MALE FEMALE

29. Corp/Co/Organization Name (see block 24) 30. City/Town Where Vehicle is Principally Garaged:
Waltham, MA
31. Mailing Address City State Zip Code
1 Dolores Avenue, Unit 3 Waltham NH 02452
32. Residential or Corp/Co/Organization Address (see block 24 and 29) City State Zip Code

33A. Lessee’s MA License Number or EIN/FID Number. If out-of-state Lessee, use SSN and date of birth. 33B. Lessee’s Name:
M M D D Y Y

34. Lessee’s Address, City, State, and Zip Code Sales or Use Tax Schedule
56 A. SALE BY LICENSED MOTOR VEHICLE DEALER
35. Date of Purchase 36. Odometer Reading
Title 05/06/2016 181,571
MA DOR-Registered Dealer EIN/FID # ______________________

Total Sale Price $ ______________________

37. q New Vehicle 38. Title Type: q Clear q Salvage q Reconstructed
(adjusted for dealer’s discount and manufacturer’s rebate)
✔Used Vehicle
q q Owner Retained q Theft q Prior Owner Retained
Less Manufacturer’s Excise $ ______________________
39. Primary Salvage Title Brands: 40. Secondary Salvage Brand(s)
qRepairable q Parts Only Net Sales Price $ ______________________

Lienholder 41. Date of 1st Lien 42. Date of 2nd Lien

Less Trade-in Allowance For: $ ______________________
I/we certify that all liens on this vehicle are listed below
43. First Lienholder Code 44. Name Yr __________ Make_____________ Model_______________

Trade-in VIN ___________________________________________

45. Lienholder’s Address
Taxable Sales Price $ ______________________

6.25% Sales Tax $ ______________________

46. Second Lienholder Code 47. Name
B. SALES BY OTHER THAN MOTOR VEHICLE DEALER
48. Lienholder’s Address
Gross Sales Price (Proof Required) $ ______________________

6.25% Sales/Use Tax $ ______________________

Insurance Certification The company signatory hereto hereby certifies that it has or will insure or guarantee performance by the applicant
hereinbefore named with respect to the motor vehicle hereinbefore described for a period at least coterminous with
that of such registration under a motor vehicle liability policy, binder or bond which conforms to the provisions of general laws, Chapter 175, Section 113A, and that the premium
C. CLAIM EXEMPTION FROM TAX CODE: __________________
charge and classification on the effective date of registration are as established by the commissioner of insurance under Chapter 175, Section 113B, 113H and Chapter 175E.
Form Attached (if required)
49A. Policy Effective Date: _____________________ Exempt Organization Certificate #__________________________
49A. Policy Change Date: _____________________
Fee Info.
49B. Manual Class: 49C. Ins. Company & Code:
Insurance Co’s Authorized Representative’s Signature (Original Only) 57. Reg: $ ___________________ Payment:
I/We the applicants hereby certify under the penalties of perjury that there are no outstanding excise tax liabilities on the vehicle
Signatures Title: $ ___________________ q Cash
described above that have been incurred by the applicant(s), any member of the applicant’s immediate family who is a member of
the applicant’s household or the business partner of the applicant(s). I/We hereby further certify that all information contained in this application is true Tax: $ ___________________ q Check
and correct to the best of my knowledge and belief. I/We understand that false statements are punishable by fine, imprisonment or both.
50. Signature of Owner From Block 25 or 29. If owner is listed in Block 29, signer must also print name. P&I: $ ___________________ q EFT/ CC
Total: $ ___________________ Clerk ID:
51. Signature of 2nd Owner From Block 27.
58. Batch No:

52. Authorized Dealer’s Signature 53. Dealer Reg. No.

59. Clerk/End User Initials:
54. Seller’s Name (Please Print)

55. Seller’s Address Progressive Ins. form approved 1/2013

This form approved by the RMV 1/2013 www.massrmv.com
 REGISTRANT
Massachusetts Department of Transportation 3. Number of Documents______ rRO (Registration Only) ✔RX (Registration Transfer)
r
RMV-1 Application Form 4. rST (Salvage Title) rRT (Registration & Title) rTAR (Title Add Registration)
www.massrmv.com
1. REG. EFF. DATE 2. REG. EXP. DATE rTO (Title Only) rSW (Summer/Winter Swap) rSS (Surviving Spouse)
5. Plate Type 6. Registration Number 7. Previous Title # 8. State
Registration/Vehicle PASS 4010348 13939139 NH
9. Type of Registration: 10. Vehicle Identification Number:
✔Passenger qBus qTaxi qLivery qCommercial
q
q Trailer q Auto Home q Semi-Trailer q Motorcycle q Other ________________
2HGFA16596H524365
11. Year 12. Make 13. Model Name 14. Model # 15. Body Style 16. Circle Color(s) of Vehicle 2-Blue 17. # of Cylinders/Passengers/Doors/Wheels
0-Orange 1-Black ●
2006 Honda Civic 4DSED 3-Brown 4-Red 5-Yellow 6-Green 7-White 8-Gray 9-Purple 4 / 4 / 4 / 4
18. Transmission 19. Total Gross Weight (Laden) 20. Motor Power ✔Gasoline
q 21. Bus: q Regular q DTE q Livery q Taxi q School Pupil
✔Automatic
q q Diesel q Propane q Electric If carrying passengers for hire, max no of passengers that can be seated: ________
q Manual q Hybrid q Other ___________ If school bus, is it used exclusively for city, town, or school district? q Yes q No
22. Owner 1 License # / ID # / or SSN 23. Owner 2 License # / ID # / or SSN 24. EIN/FID # (See block 29) If Sole Proprietor
Owner S11340092 provide SSN in # 22

25. Owner # 1 Name (Last, First, Middle) 25a. Height 25b. Sex 26. Owner # 1 Date of Birth
_____
5 10
Ft _____ In ✔ MALE FEMALE
Smith, Eric David 05/04/1995
27. Owner # 2 Name (Last, First, Middle) 27a. Height 27b. Sex 28. Owner # 2 Date of Birth
_____ Ft _____ In MALE FEMALE

29. Corp/Co/Organization Name (see block 24) 30. City/Town Where Vehicle is Principally Garaged:
Waltham, MA
31. Mailing Address City State Zip Code
1 Dolores Avenue, Unit 3 Waltham NH 02452
32. Residential or Corp/Co/Organization Address (see block 24 and 29) City State Zip Code

33A. Lessee’s MA License Number or EIN/FID Number. If out-of-state Lessee, use SSN and date of birth. 33B. Lessee’s Name:
M M D D Y Y

34. Lessee’s Address, City, State, and Zip Code Sales or Use Tax Schedule
56 A. SALE BY LICENSED MOTOR VEHICLE DEALER
35. Date of Purchase 36. Odometer Reading
Title 05/06/2016 181,571
MA DOR-Registered Dealer EIN/FID # ______________________

Total Sale Price $ ______________________

37. q New Vehicle 38. Title Type: q Clear q Salvage q Reconstructed
(adjusted for dealer’s discount and manufacturer’s rebate)
✔Used Vehicle
q q Owner Retained q Theft q Prior Owner Retained
Less Manufacturer’s Excise $ ______________________
39. Primary Salvage Title Brands: 40. Secondary Salvage Brand(s)
qRepairable q Parts Only Net Sales Price $ ______________________

Less Trade-in Allowance For: $ ______________________

Yr __________ Make_____________ Model_______________

Trade-in VIN ___________________________________________

Taxable Sales Price $ ______________________

6.25% Sales Tax $ ______________________

B. SALES BY OTHER THAN MOTOR VEHICLE DEALER

Gross Sales Price (Proof Required) $ ______________________

6.25% Sales/Use Tax $ ______________________

Insurance Certification The company signatory hereto hereby certifies that it has or will insure or guarantee performance by the applicant
hereinbefore named with respect to the motor vehicle hereinbefore described for a period at least coterminous with
that of such registration under a motor vehicle liability policy, binder or bond which conforms to the provisions of general laws, Chapter 175, Section 113A, and that the premium
C. CLAIM EXEMPTION FROM TAX CODE: __________________
charge and classification on the effective date of registration are as established by the commissioner of insurance under Chapter 175, Section 113B, 113H and Chapter 175E.
Form Attached (if required)
49A. Policy Effective Date: _____________________ Exempt Organization Certificate #__________________________
49A. Policy Change Date: _____________________
Fee Info.
49B. Manual Class: 49C. Ins. Company & Code:
Insurance Co’s Authorized Representative’s Signature (Original Only) 57. Reg: $ ___________________ Payment:
_ Title: $ ___________________ q Cash
CERTIFICATE OF REGISTRATION Tax: $ ___________________ q Check
P&I: $ ___________________ q EFT/ CC
Total: $ ___________________ Clerk ID:
This document is the Certificate of Registration for the herein
described vehicle. Section 11, Chap. 90, MGL states ...”Every 58. Batch No:
person operating a motor vehicle shall have the Certificate of
Registration for the vehicle and for the trailer, if any, and his 59. Clerk/End User Initials:
license to operate, upon his person or in the vehicle in some
easily accessible place.”
Not Valid Until Stamped With Official Stamp or Registrar’s Signature
Progressive
This form approved by the Ins. form
RMV 1/2013 approved 1/2013
www.massrmv.com