Application For Certificate Of Title To A Motor Vehicle

Type or Print in Ink · CHECK TYPE(S) OF APPLICATION(S). Fee of $ 5.00 for failure to apply for title within 30 days of assignment. ANTHONY J. DATTILIO Clerk of Courts ­ Columbiana County APPLICATION(S) FOR CERTIFICATE OF TITLE Applicant's Name: Applicant's Address: hereby declares under penalty that he/she is the lawful (owner / purchaser / lien holder) of the following described motor vehicle and hereby makes application(s) for the following: ORIGINAL CERTIFICATE OF TITLE MCO, SALVAGE CERTIFICATE OF TITLE MEMORANDUM CERTIFICATE OF TITLE for Certificate of Title Number: Applicant acquired said motor vehicle from previous owner: Address of Previous Owner: } Evidence of Ownership: Previous Title No., Registration, etc. Vendor#: Dealer Permit#: The following is a full statement if all liens on said motor vehicle. If no lien, state "none". If more than one lien, attach statement of all additional liens. Lien Holder: DUPLICATE CERTIFICATE OF TITLE Applicant states that Certificate of Title Number: has been sold or disposed of and no liens or encumbrances exist except as stated below. The (vehicle / title) is in the possession of ; that said motor vehicle has not been Address: Lien Holder, Owner, Etc. residing at and that if said Certificate of Title be hereby recovered by this applicant, same will be delivered to the Clerk of Courts for cancellation. ODOMETER CERTIFICATION Federal and State laws require that you state the mileage in connection with transfer of ownership or applying for a duplicate Certificate of Title. Failure to complete or providing false information may result in fines and/or imprisonment. I (we) certify to the best of my (our) knowledge that the odometer now reads and is that actual mileage of the vehicle unless one of the following statements is checked. The mileage stated is in excess of the mechanical limits. VIN: Model: Purchase Price: $ Ohio Sales or Use Tax Paid: $ Condition of vehicle (check only one): Yes Reason: Tax Exemption: The odometer reading is not the actual mileage WARNING ­ ODOMETER DISCREPANCY Body Type: Make: Year: Conversion: Trade in Amount: $ Tax Base: Vendor Disc. $ Tax Remitted: $ Good Fair Poor Wrecked Sales Credit Amount: $ Warning! You are required by law to state the true selling price. A false statement is in violation of Section 2921.13 of the Ohio Revised Code and is punishable by six months imprisonment and a fine of up to one thousand dollars or both. All transfers are audited by the Department of Taxation. The seller and buyer must provide any information requested by the Department of Taxation. The buyer may be assessed any additional tax found to be due. Applicant's Signature: Sworn to and subscribed in my presence by My commission expires (seal) Clerk, this day of Deputy Clerk of Courts - Notary American LegalNet, Inc. www.FormsWorkFlow.com