I, , I hereby certify that on or about
, 20 , I transferred my interest in the following described
vehicle, year , make , and vehicle identification number
by executing an assignment and warranty of title to the transferee in the space provided therefore
on the Certificate of T
itle, and/or executing the applicable portions of the vehicle transaction
record (TC-96-182) as provided by KRS 186A.215(1).
I request further registration on this vehicle be restricted as provided by law until this transfer has
been processed.
Subscribed and sworn to before me this
day of , 20
Signature of Owner(s)
City, State, Zip Code
Owner’s SSN
My Commision Expires
KRS 186A.215(4) If it comes to the attention of a transferor that a transferee did not promptly
submit the necessary document within fifteen (15) calendar days to the county clerk as required
by law in order to complete the transfer transaction, a transferor shall submit to the county clerk,
in his county of residence, an affidavit that he has transferred his interest in a specific vehicle and
the clerk shall enter appropriate data into the
AVIS system which shall restrict any registration
transaction from occurring on that vehicle until the transfer has been processed.