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PLEASE TYPE OR PRINT INFORMATION , s
REQUIREMENTS: Federal and State law requires that you state the mileage in connection with the transfer of ownership. Failing to complete this form,or providing
any false statements may result in fines and/or imprisonment.
TO SELLER: Seller is responsible for completing this form. If title is issued in more than one name,all owners listed on the title must sign as Seller. Do not
sign as a Seller until all areas of the assignment are completed. Any person signing on behalf of a company must state their position.
a TO PURCHASER: You must apply for a new certificate of title within forty-five days of the date of purchase,
ora newa tl an
administrative penalty.All liens,mortgages or
other encumbrances shown on the face of this title must be released before you apply for
No
I/we,as Seller,certify that to the best of my/our knowledge the information contained hecked. _ II -. I-- ' I t l it Tenths
on this document is true and correct and that the odometer now reads and is the _ MILES
ACTUAL MILEAGE of the vehicle unless one of the following statements is the odometer reading is not actual mileage WARNING ODOMETER DISCREPANCY.
Li The odometer reading stated is in excess of its mechanical limits. LJ
For value received,I/we hereby sell,assign and transfer the vehicle described on this document and warrant title to Purchaser.
----- - ---- - PURCHASER INFORMATION
SELLER INFORMATION Dealer Number
Position(if applicable) Name of Purchaser
Signature of Seller ---
-
Signature of Seller Position
_ City --State Zip Code
------" -- Dealer Number(if applicable)
Printed Name of Seller
Holder of lien,mortgage or encumbrance(if applicable)
Printed Name of Seller ddress
.__- Zip Code
Date of Sale(,,.,.,m,day,rear Selling Pnce Trade in Price(if any)Total Price Paid City State — —_
I AM AWARE OF THE ABOVE ODOMETER CERTIFICATION MADE BY THE SELLER(S)
Signature of Purchaser Printed Name of Purchaser
FIRST RE-ASSIGNMENT BY REGISTERED DEALER ONLY Dealer Number
Name of Purchaser
I/we,as Seller,certify that to the best of my/our _ _
knowledge the information contained on this document I I pi C7 I 1[ 1[ 1
_ - ddress
is true and correct and that the odometer now reads
and is the ACTUAL MILEAGE of the vehicle unless one --"--- (State Zip Code
Zip Code
of the following statements is checked. City
❑ The odometer reading stated ism excess of its mileage -- - --�
mechanical limits. WARNINGODOMETER DISCREPANCY. Holder of lien,mortgage or encumbrance(if applicable)
Name of Dealership - --
I
ddress
Signature City (State
Printed Name I AM AWARE OF THE ABOVE ODOMETER CERTIFICATION MADE BY THE SELLER(S)
Printed Name of Purchaser
Position (aw Dealer Number Signature of Purchaser
Date of Sale xh,Oaf,NZ;
odometer reading is not actual
SECOND RE-ASSIGNMENT BY REGISTERED DEALER ONLYI/we, Dealer Number
( Name of Purchaser
as Seller,certify that to the best of my/our [-I r-1 L I 'r_ 1 r-1 L i
knowledge the information contained on this document _ _-_-._.--- --------
is true and correct and that the odometer now reads Address _ —
and is the ACTUAL MILEAGE of the vehicle unless one
of the following statements is checked. City (State Zip Code
The odometer reading is not actual Y
LiThe odometer reading stated is in excess of its I-� mileage
mechanical limits. WARNING ODOMETER DISCREPANCY. Holder of lien,mortgage or encumbrance(if applicable)
Name of Dealership - -
ddress -----
Signature
City State Zip Code
Printed Name "---- -
I AM AWARE OF THE ABOVE ODOMETER CERTFIIFICATION MADE BY THE SELLER(S)__-- _ - 1Printed Name of Purchaser
Position _ (Dealer Number — - - Signature of Purchaser
Date of Sale Oaa^ta,day,veal
•
THIRD RE-ASSIGNMENT BY REGISTERED DEALER ONLY (Dealer Number
Name of Purchaser —11
I/we,as Seller,certify that to the best of my/our - - __ ____
knowledge the information contained on this document I I I I I I ,I If L..1 Address
is true and correct and that the odometer now reads L_J
and is the ACTUAL MILEAGE of the vehicle unless one -
`� City State ZiP Code
of the following statements is checked. The odometer reading is not actual
. odeterading stated is in excess of its 11 mileage -
❑The mechanicomal limitre . WARNING ODOMETER DISCREPANCY. Holder of lien,mortgage or encumbrance(if applicable)
tr
Name of Dealership
Address ----------���
Signature City State (Zip Code
Ii
Printed Name I AM AWARE OF THE ABOVE ODOMETER CERTIFICATION MADE BY THE SELLER(S)
a: _ rinted Name of Purchaser
Position (Dealer Number Signature of Purchaser l
Date of Sale t,mai.,day,mar)
I NO ADDITIONAL RE-ASSIGNMENTS PERMITTED__