MAKE YEAR VEHICLE IDENTIFICATION NUMBER TITLE NUMBER
Owner's Last Name
FIRST NAME(S) MIDDLE NAME
Street, RFD
CITY STATE ZIP
CERTIFICATION
I/We, the registered owner or lienholder of the above described vehicle, hereby make application for a Replacement Certificate of Title and certify that the
original has been
(Check appropriate box.)
Lost Never received from the Department
Mutilated, Destroyed or Illegible: Stolen;
Never received from the Lienholder;
Other (State why replacement is applied for if none of above apply)
TO: MISSISSIPPI FAST TRACK TITLE PROGRAM
P. O. BOX 22845 JACKSON, MS 39225-2845
READ &
CHECK
HERE
Applicant hereby directs the Department of Revenue to mail or deliver the title herein applied for as shown below.
COMPLETE THIS SECTION, PRINTING OR TYPING ALL INFORMATION
I, the undersigned hereby certify that I am the recorded owner or lienholder of the above described vehicle.
Owner's Signature
Joint Owner's Signature
Lienholder's Name
Agent
(Signature of Lienholder Authorized Representative)
Date
,20
MONTH DAY YEAR
MADE BY OWNER:
If a lienholder was shown on the original title, a lien release must be included with this replacement
application. Application must be signed by owner (s). If title is in a business name, person signing application must list
their position in the company next to their signature.
Example: John Doe, President
MADE BY LIENHOLDER:
If lienholder directs Department of Revenue to mail title to owner, a lien release must be
included and owner(s) must sign application. If no lien release is provided and owner(s) does not sign, replacement
title will be mailed to lienholder as shown on title.
(NAME)
(STREET / APT. / P.O. BOX)
CITY STATE ZIP
I/We understand that upon issuance of the replacement title, the original title becomes void and must be returned to the Department of
Revenue should it be found. I/We also understand the replacement title shall contain the legend "this is a replacement certificate
and may be subject to the rights of a person under the original certificate."
IF NAME
ENTERED HERE
IS OTHER
THAN TITLE
OWNER.
ATTACH
APPROPRIATE
POWER OF
ATTORNEY.
DEALERS
ATTACH COPY 3
OF FORM
79-006 / 78-004.
OTHERS USE
78-003.
Fee for Replacement Title is payable by Cashier's Check,
Personal Check, Certified Check or other form of Certified funds.
780261781000
FEE OF $39.00
SEE INSTRUCTIONS ON
REVERSE S
IDE OF FORM
FAST TRACK Application for Replacement Certificate of Title
Mississippi
