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Georgia Department of Revenue - Motor Vehicle Division
Application to Extend the Initial Registration Period
ANY CORRECTION OR ALTERATION WILL VOID THIS AFFIDAVIT
Purpose of this Affidavit: This affidavit should be used by a vehicle transferor or transferee to request an extension of the initial registration period for a motor
vehicle for which the transferor or lienholder has not delivered the title to the transferee. This form should be submitted no sooner than five (5) business days prior
to the expiration of the original temporary operating permit (license plate).
How to submit this Affidavit: This affidavit must be completed in its entirety, legibly printed in blue or black ink or typed, and submitted along with the required
document to the county tag office in the county where the transferee resides. Please refer to http://dor.georgia.gov/motor-vehicles to locate the county tag office
in the transferee’s county of residence.
Required Document: Copy of the motor vehicle bill of sale or dealer’s invoice.
Primary Owner’s
Full Legal Name:
Address:
State: ZIP Code: Telephone No.:
Secondary Owner’s
Full Legal Name:
Address:
State: ZIP Code: Telephone No.:
No. (VIN):
Make: Model:
Seller/Transferor’s
Full Legal Name:
Full Legal Name (First, Middle Initial, Last, Suffix) / Business Name / Leasing Company Name
Purchase Date:
/ /
I/We, the transferor or transferee request that ______________________________________ County Tag Agent extend the initial registration period for this
vehicle and issue a County Tag Agent temporary operating permit to expire thirty (30) days from issuance.
I/We also acknowledge and understand that any false statement submitted is punishable under the law and may result in a denial of my/our request.
Transferor’s or Transferee’s
Printed Name:
Title:
Transferor’s or Transferee’s
Signature:
Date: / /
NOTARY PUBLIC ACKNOWLEDGMENT
Sworn to and subscribed before me this
day of
,
Notary Seal or Stamp
Notary Public’s
Full Legal Name:
-mail Address: Telephone No.:
Signature of
Notary Public:
Commission Expires:
/ /