OFFICE USE ONLY
KANSAS
Department of Revenue
Division of Vehicles
www.ksrevenue.org/dmv
Validation Number
D#
APPLICATION FOR TITLE
REASSIGNMENT ADDENDUM
Title Reassignment
Addendum
@ $32.50 per bundle = $
Sold in multiplies of 5 (bundle) No. of Bundles ($6.50 per addendum X 5 per bundle)
Dealer Licensing Phone Number: Office (785) 296-3621
Fax (785) 296-5854
Dealer Business Name
DBA (If applicable)
Business Street Address
City State ZIP
Business Telephone Number
By my signature I swear or affirm that this is a true and correct statement. I am aware that the law provides severe
penalties for making false statements under oath.
Owner, Manager or
Corp. Officer Signature
Position with
Dealership
Cannot be Signed by Person Using Power of Attorney
Hand Printed Name of
Person that Signed Above Date
Only an owner, manager or corporate officer of the dealership can sign this form. A power
of attorney or any other form of authorization cannot be used to sign.
All information requested on this application must be provided.
To insure the speedy processing of your order:
Make your check or money order for the correct amount, payable to the Kansas
Department of Revenue.
Your Vehicle Dealer Monthly Sales Reports, Bond, and Insurance must be current.
If your dealership has changed its business name and/or business location, please contact
the Dealer Licensing Bureau immediately at the phone number shown above.
Mail completed application with payment attached to: Kansas Department of Revenue
Division of Vehicles
PO Box 2369
Topeka, Kansas 66601-2369
TR-69www (06/19)
