For more information, please call: 410-768-7000 (to speak with a customer agent).
TTY for the hearing impaired: 1-800-492-4575. Visit our website at: www.MVA.Maryland.gov
APPLICATION FOR CERTIFICATE OF TITLE
VR-005
(06-13)
READ INSTRUCTIONS ON REVERSE SIDE
Motor Vehicle Administration
6
601 Ritchie Highway, N.E.
G
len Burnie, Maryland 21062
A
PPLICANT’S FIRST NAME MIDDLE LAST CO-APPLICANT’S FIRST NAME MIDDLE LAST
APPLICANT’S SOUNDEX/MARYLAND DRIVER’S LICENSE NO. DATE OF BIRTH CO-APPLICANT’S SOUNDEX/MARYLAND DRIVER’S LICENSE NO. / FEIN # DATE OF BIRTH
MONTH DAY YEAR MONTH DAY YEAR
A
PPLICANT’S STREET ADDRESS CITY OR TOWN CO-APPLICANT’S STREET ADDRESS CITY OR TOWN
COUNTY STATE ZIP CODE EMAIL ADDRESS COUNTY STATE ZIP CODE EMAIL ADDRESS
IS THE VEHICLE TO BE TITLED AS JOINT TENANTS OR TENANTS BY ENTIRETIES? JOINT TENANTS TENANTS BY ENTIRETIES
NEW VEHICLE
U
SED VEHICLE
M
ODEL YEAR
M
AKE OF VEHICLE
M
ODEL NO. VEHICLE IDENTIFICATION NUMBER
M
ODEL YEAR
M
AKE OF VEHICLE
T
YPE OF FUEL
#
OF CYLINDERS MOTOR CARRIER # UNIT #
T
WO STAGE VEHICLE
C
OMPLETE MAKE & YEAR
F
OR EACH VEHICLE
TRUCK
TRUCK TRACTOR
G.V.W. G.C.W. AXLES
B
US
S
EATS
M
OTORCYCLE
E
NGINE NO. ENGINE SIZE (C.C.)
T
RAILER (SPECIFY LENGTH)
G
.V.W. TYPE OF TRAILER
If this vehicle is subject to any liens or encumbrances, complete the following section(s). Attach form VR-217 for additional Lien Filings.
/,(1),/,1*)((IRUHDFK/LHQĺOHG,)12768%-(&772$/,(1:5,7(7+(:25'q121(r%(/2:
NAME OF SECURED PARTY
C
ITY OR TOWN
S
TREET ADDRESS OF SECURED PARTY KIND OF LIEN (DESCRIBE)
D
ATE OF LIEN
S
TATE ZIP CODE
AMOUNT OF LIEN ACCOUNT NUMBER
IF VEHICLE RECENTLY PURCHASED MARYLAND DEALER’S CERTIFICATION DEALERS ONLY
MD. EXCISE
TAX 6% OF $_______________________
FULL PURCHASE PRICE
ATTACH A NOTARIZED BILL OF SALE SIGNED BY
S
ELLER(S) AND PURCHASER(S)
I hereby certify, under penalty of perjury, that the purchase price represents the full
a
mount paid for this vehicle.
Date of Delivery
D
EALER’S NUMBER N U
N
AME OF DEALERSHIP
S
IGNATURE OF DEALER DATE
CERTIFIED
SELLING PRICE
T
RADE-IN ALLOWANCE
TAXABLE PRICE
GROSS TAX COLLECTED
C
OLL. FEE .6% OF GROSS OR $12 MAX. FEE ALLOW.
N
ET TAX REMITTED
VEHICLE DESCRIPTION
PURCHASE INFORMATION FOR TAX PURPOSES – SEE INFORMATION ON REVERSE SIDE
VIN OF TRADE-IN _______________________________________________ _________________________ STATE ___________________________________________
APPLICATION FOR NEW REGISTRATION PLATES OR TRANSFER OF REGISTRATION PLATES
I/we do hereby make application for:
New Tags
Transfer of Tags
Title Only Is your motor vehicle now suspended or revoked in this or any
other state?
Yes
No Is this vehicle to be operated for short term rental?
Yes
No If transferring plates, complete below:
TAG NO. __________________________________ and STICKER NO. ___________________________ 7KHYHKLFOHWRZKLFKWKHVHSODWHVZHUHDIĺ[HGKDVEHHQVROG
traded or otherwise transferred to: Name ______________________________________________________________________________________________________________
Address ___________________________________________________________________________________________________________________________________________
Name of Insurance Co. ______________________________________________________________________ Policy or Binder No. _____________________________________
Agent or broker _____________________________________________________________________________ Class of Tags desired ____________________________________
Federal and State law requires that you state the mileage in connection with this vehicle. Failure to complete or providing a false statement may result in
ĺQHVDQGRULPSULVRQPHQW
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:
ODOMETER READING _____________________ (NO TENTHS)
7KHPLOHDJHVWDWHGLVLQH[FHVVRILWVPHFKDQLFDOOLPLWV
2.
The odometer reading is not the actual mileage. WARNING – ODOMETER DISCREPANCY.
,ZHFHUWLI\WKDW,ZHKDYHFRPSDUHGWKHPDQXIDFWXUHUpVYHKLFOHLGHQWLĺFDWLRQQXPEHURQWKLVDSSOLFDWLRQZLWKWKHQXPEHURQWKHYHKLFOHDQGWKH\DJUHHDQGWKDWWKLVYHKLFOHLVVXEMHFWWRWKHOLHQVRU
encumbrances indicated herein and none other. For vehicles registered over 10,000 lbs. by signing this application, I/we certify knowledge of the Federal and State Motor Carrier Safety Laws and
certify this vehicle is maintained in compliance with the Maryland Preventive Maintenance Program. If making application for new plates or transfer of registration plates I/we certify under Penalty of
Law that the vehicle is covered by at least the minimum amounts of insurance required by the Maryland Motor Vehicle Laws, and further certify that this vehicle will be continuously insured throughout
its registration period. I/W
e further certify under Penalty of Perjury that the statements
made herein are true and corr
ect to the best of my knowledge, information and belief.
Signature of Applicant
__________________________________________________________
Printed Name of Applicant
_____________________________________
Signature of Co-Applicant
______________________________________________________
Printed Name of Co-Applicant
__________________________________
Witness my/our Hand(s) and Seal(s) this
______________
day of
________________
year
_______________________
Signature of Co-Signer
_________________________________________________________
Relationship
_ _ __ _ _ _ _ __ _ _ _ __ _ _ _ __ _ _ _ _ __ _ _ _ __ _ _ _ __ _ _ _ _ __ _ _ _ __ _ _ _
6RXQGH[
______________________________________________________________________
Date of Birth
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
&
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,
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Check here if active duty military.
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