1. REG. EFF . DATE 2. REG. EXP . DATE
3. Number of Documents______
rRO (Registration Only) rRX (Registration Transfer)
4. rST (Salvage Title) rRT (Registration & Title) rTAR (Title Add Registration)
rTO (Title Only) rSW (Summer/Winter Swap) rSS (Surviving Spouse)
Registration/Vehicle
6. Registration Number 7. Previous Title # 8. State
9. Type of Registration: 10. Vehicle Identication Number:
qPassenger qBus qTaxi qLivery qCommercial
qTrailer qAuto Home qSemi-Trailer qMotorcycle qOther________________
11. Year 12. Make 13. Model Name 14. Model # 15. Body Style 16. Circle Color(s) of Vehicle 0-Orange 1-Black 2-Blue 17. #
of Cylinders/Passengers/Doors/Wheels
3-Brown 4-Red 5-Yellow 6-Green 7-White 8-Gray 9-Purple
/ / /
18. Transmission 19.
Total Gross Weight (Laden)
20. Motor Power qGasoline 21. Bus: qRegular qDTE qLivery qTaxi qSchool Pupil
qAutomatic qDiesel qPropane qElectric If carrying passengers for hire, max no of passengers that can be seated: ________
qManual q Hybrid qOther ___________ If school bus, is it used exclusively for city, town, or school district? qYes qNo
24. EIN/FID # (see block 29)
25. Owner # 1 Name (Last, First, Middle)
27. Owner #
2 Name (Last, First, Middle)
29.
Corp/Co/Organization Name (see block 24) 30. City/Town Where Vehicle is Principally Garaged:
31.
Mailing Address City State Zip Code
32. City State Zip Code
33A. Lessee’s MA License Number or EIN/FID Number. If out-of-state Lessee, use SSN and date of birth. 33B. Lessee’s Name:
34. Lessee’s Address, City, State, and Zip Code
36. Odometer Reading
37. qNew Vehicle 38. Title Type: qClear qSalvage qReconstructed
qUsed Vehicle qOwner Retained qTheft qPrior Owner Retained
39.
Primary Salvage Title Brands: 40. Secondary Salvage Brand(s)
q Repairable qParts Only
41. Date of 1st Lien 42. Date of 2nd Lien
43.
First Lienholder Code 44. Name
45. Lienholder’s Address
46.
Second Lienholder Code 47. Name
48. Lienholder’s Address
Lienholder
I/we certify that all liens on this vehicle are listed below
Insurance Certication
The company signatory hereto hereby certies that it has or will insure or guarantee performance by the applicant
hereinbefore named with respect to the motor vehicle hereinbefore described for a period at least coterminous with
that of such registration under a motor vehicle liability policy, binder or bond which conforms to the provisions of general laws, Chapter 175, Section 113A, and that the premium
charge and classication on the effective date of registration are as established by the commissioner of insurance under Chapter 175, Section 113B, 113H and Chapter 175E.
49A. Policy Effective Date: _____________________
49A. Policy Change Date: _____________________
49B. Manual Class: 49C. Ins. Company & Code:
Insurance Co’s Authorized Representative’s Signature (Original Only)
Signatures
I/We the applicants hereby certify under the penalties of perjury that there are no outstanding excise tax liabilities on the vehicle
described above that have been incurred by the applicant(s), any member of the applicant’s immediate family who is a member of
50. Signature of Owner From Block 25 or 29. If owner is listed in Block 29, signer must also print name.
51. Signature of 2nd Owner From Block 27.
52.
Authorized Dealer’s Signature 53. Dealer Reg. No.
54. Seller’s Name (Please Print)
55. Seller’s Address
the applicant’s household or the business partner of the applicant(s). I/We hereby further certify that all information contained in this application is true
and correct to the best of my knowledge and belief. I/We understand that false statements are punishable by ne, imprisonment or both.
56 A. SALE BY LICENSED MOTOR VEHICLE DEALER
MA DOR-Registered Dealer EIN/FID # ______________________
Total Sale Price $ ______________________
(adjusted for dealer’s discount and manufacturer’s rebate)
Less Manufacturer’s Excise $ ______________________
Net Sales Price $ ______________________
Less Trade-in Allowance For: $ ______________________
Yr __________ Make_____________ Model_______________
Trade-in VIN ___________________________________________
Taxable Sales Price $ ______________________
6.25% Sales Tax $ ______________________
B. SALES BY OTHER THAN MOTOR VEHICLE DEALER
Gross Sales Price (Proof Required) $ ______________________
6.25% Sales/Use Tax $ ______________________
C. CLAIM EXEMPTION FROM TAX CODE: __________________
Form Attached (if required)
Exempt Organization Certicate #__________________________
57.
Reg: $ ___________________ Payment:
Title: $ ___________________ q Cash
Tax: $ ___________________ q Check
P&I: $ ___________________ q EFT/ CC
Total: $ ___________________ Clerk ID:
59. Clerk/End User Initials:
Sales or Use Tax Schedule
Fee Info.
58. Batch No:
ORIGINAL
M M D D Y Y
Owner
Registration/Vehicle
Title
Massachusetts Department of Transportation
Owner # 2 License # / ID # / or SSN
If Sole Proprietor
provide SSN in #22
25a. Height
_____ Ft _____ In
27a. Height
_____ Ft _____ In
Owner # 1 License # / ID # / or SSN
Residential or Corp/Co/Organization Address (see block 24 and 29)
Progressive Ins. form approved 1/2013
This form approved by the RMV 1/2013 www.massrmv.com
