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--` MANUFACTURED (MOBILE) HOME PERMI1 1I S ,
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ATTENTION: MOVER HAULER O:TO':YEF.
SECTION A-MOVING PERMIT
t .s L _ -3" ,1 . J. n. .. v`} ', •, ..'l:y. ' %Y^+."ier "''' z�?J"91 ? y --
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% PLEASE TYPE Oft PRINT INFORMATION
` REQUIREMENTS: Federal and State law requires that you state the mileage?n connection witn the transfer of ownership.Failure to complete,or providing false
statement may result in fines and or imprisonment.
TO SELLER: Seller is responsible for completing form.If title is in more than one name,all owners listed on the title must sign as seller.Do not sign as a Seiler
1` until all areas of the assignment are completed.Any person signing for a company must state position.
TO PURCHASER: You must apply for a new certificate of title within thirty-one days of the daze of purchase,or pay a delinquent penalty fee.All liens shown on the
face of this title must be released before you apply for a new title.
ri •I I r-II I _ ❑ The odometer reading stated:s in excess of its ddres5
mechanical limps.
❑ The odometer reading is not actual mileage City `State (Zip Code
WARNING ODOMETER DISCREPANCY. y
Name of Dealership
Name of Lienholder(if applicable)
Signature
AHAreSs
Printed Name
City State Zip Code
Position Dealer Number _
I AM AWARE OF THE ABOVE ODOMETER CERTIFICATION MADE BY THE SELLER(S)
Date of Sale(..oaln.day.yea., Signature of Purchaser tinted Name of Purchaser
SECOND RE-ASSIGNMENT BY REGISTERED DEALER ONLY
I certify to the best of my knowledge that the odometer reading Is the ACTUAL 1 Name of Purchaser (Dealer Number
MILEAGE of the vehicle unless one of the following statements is checked.
I I I II I , I I LJLJ ❑ Thecne odanical oometerm remrading stated is in excess of its Address -
the odometer reading is not actual mileage City (State-- Zip Code
WARNING ODOMETER DISCREPANCY. Y
Name of Dealership
Name of Lienholder(if applicable)
Signature Address
Printed Name
City 'State Zip Code
Position Dealer Number
I AM AWARE OF THE ABOVE ODOMETER CERTIFICATION MADE BY THE SELLER(S)
Date of Sale v.o,xn•day.yd.', Slgnatu re of Purchaser Printed Name of Purchaser
THIRD RE-ASSIGNMENT BY REGISTERED DEALER ONLY
I certify to the best of my knowledge that the odometer reading is the ACTUAL Name of Purchaser Dealer Number
MILEAGE of the vehicle unless one of the following statements is checked.
III II 1 , 1 II II I ❑The odomanicallieter readingmits. stated ism excess of its Address
f l The odometer reading is not actual mileage City State Zip Code
WARNING ODOMETER DISCREPANCY. y
Name of Dealership
Name of Lienholder(IT applicable)
Signature Address
Printed Name
City (State Zip Code
Position u Dealer Nmber
I I AM AWARE OF THE ABOVE ODOMETER CERTIFICATION MADE BY THE SELLER(S)
Date of Sale lm,rxn.aay,yore Signature of Purchaser Printed Name of Purchaser
I NO ADDITIONAL RE-ASSIGNMENTS PERMITTED I