APPLICATION FOR DUPLICATE/REPLACEMENT
LICENSE PLATE OR DECAL
(T.C.A. 55-4-103(b)(4)(g))
Check the appropriate box:
Duplicate Plate ____________________________
(
Plate Format) Class Code/Issue Year
Replacement Plate __________________________ ____________________________
License Plate Number
Class Code/Issue Year
Replacement Decal __________________________
Decal Number
_________________________________ _____________________ ____________________
VIN Make Yr. Model
I certify that the above listed license plate or decal, issued for the vehicle herein described, has been
lost , stolen or mutilated . I further certify that I have reported the loss or theft of this plate or
decal to the following local Law Enforcement Agency.
________________________________________ ______________________________________
Law Enforcement Agency Officer’s Name
Note: A duplicate plate will not be issued until the holder affirms that proper law enforcement
notification has been made.
Under penalties of perjury, I hereby certify this information is correct to the best of my knowledge.
________________________________________ ________________________________
Owner/ Certifier Date
Sworn to and subscribed before me this the _____________________ day of _______________________,
20_________.
__________________________________________________
Notary Public
My commission expires: _______________________________________________________________
RV-F1315301 RDA 692
Tennessee Department of Revenue
Taxpayer and Vehicle Services Division
44 Vantage Way, Suite 160
Nashville, TN 37243-8050
