TENNESSEE DEPARTMENT OF REVENUE
TAXPAYER AND VEHICLE SERVICES DIVISION
MULTI-PURPOSE APPLICATION
COMPLETE THE SHADED
AREAS TO REQUEST A
NOTING OF LIEN
NEW OR CURRENT TITLE NUMBER
TRANSACTION
CODE*
REGISTRATION ONLY NUMBER
OWNER INFORMATION *LEGAL STATUS: 1 (AND) 2 (OR) ENTER NAME CODE IN BOX 1 (SAME) 2 (DIFFERENT) 3 (MULTIPLE LAST NAMES) 4 (COMPANY) 5 (OVER 28 CHARACTERS) MAO ILU
LAST NAME FIRST NAME MIDDLE INITIAL
LAST NAME FIRST NAME MIDDLE INITIAL
ADDRESS 1 (MAILING)
ADDRESS 2 (PHYSICAL) CITY STATE ZIP CODE
CITY STATE ZIP CODE
ADDITIONAL OWNER
CNTY OF RESIDENCE/PRINCIPAL BUS OR INCORP LOCATION
PURCHASE DATE
*LEASED
* SERVICE OPTIONS
SEE REVERSE SIDE FOR INSTRUCTIONS
TELEPHONE # *PLACARD / HEARING IMPAIRED CLS/YR *INSURANCE POLICY #
VEHICLE INFORMATION
VIN
MAKE
MODEL
YEAR
BODY
TITLE BRAND –list the appropriate code
(N) NEW (1) RECONSTRUCTED VEHICLE
(U) USED (2) FLOOD DAMAGE
(D) DEMO (3) SPECIALLY CONSTRUCTED
(8) PARTS ONLY
ODE TYPE OF FUEL - list the appropriate
code
GAS (1) ELECTRIC/HYBRID (3)
DIESEL (2) PROPANE (4)
ODE
SURRENDERED TITLE #
STATE
PREVIOUS STATES TITLED VEHICLE USE VEHICLE TYPE CURRENT MILEAGE ODOMETER ACTUAL (0) NOT ACTUAL (8)
INDICATOR OVER 10 YRS / 16,000 LBS (1)
(List one)
IN EXCESS OF MECHANICAL LIMITS (9)
ODE
COLOR CODE (enter appropriate code)*
UPPER LOWER
MOBILE HOME
LGTH WDTH
# AXLES
GROSS VEHICLE WEIGHT
*VEHICLE TRADE-IN DESCRIPTION
COMPANY VEHICLE #
PLATE INFORMATION * (required for Title and Registration and Registration Only Transactions) SEE REVERSE SIDE FOR COMPLETE INSTRUCTIONS
PLATE #(1)
CLASSCODE/ISSUEYR(1)(3) VALIDATION # (1) COUNTY STICKER # (1) CITY STICKER # (1) (2)
*PLATE # (TRADE IN) (2) CLASS CODE/ISSUE YR (2) EXPIRATION DATE (1) (2) (3)
TDS STICKER # (4)
EMP OPERATOR PERMIT # (3)
# OF SEATS (5) ZONE (COUNTY NAME) (6) USDOT / REGISTRANT # (7) MOTOR CARRIER # (8)
LIEN INFORMATION (if lien present)
LIEN CODE FIRST LIENHOLDER
LIEN DATE
STREET CITY STATE ZIP CODE
LIEN CODE SECOND LIENHOLDER
LIEN DATE
STREET CITY STATE ZIP CODE
*LESSEE / REGISTRANT INFORMATION (OWNER OF PLATE) LEGAL STATUS NAME CODE MAO ILU
NAME
NAME
ADDRESS CITY STATE ZIP CODE
VEHICLE COST / TAX INFORMATION *(required for Title & Registration Transactions)
SALE PRICE
TRADE IN ALLOWANCE TAXABLE AMOUNT SALESTAX PAID
*TAX EXEMPTION REASON / SALES TAX #
DEALER NAME
DEALER ADDRESS DEALER #
* Required for Duplicate Title – T.C.A. 55-3-115 (submit illegible or altered Certificate of Title)
LOST
STOLEN MUTILATED RTN’D DUE TO NON DELIVERY ALTERED ILLEGIBLE
Under penalties of perjury, I hereby certify all information provided is true and correct to the best of my knowledge, and acknowledge that it is not the responsibility of the Motor Vehicle Division
or its assignees to determine the accuracy of the information provided by me or on my behalf.
SIGNATURE OF CERTIFIER /OWNER
POWER OF ATTORNEY/AUTHORIZED SIGNATURE (IF APPLICABLE)
DATE
INVOICE NUMBER COUNTY NAME CO NUMBER DATE OF APPLICATION BY AUTHORITY OF REGISTRAR OF MOTOR VEHICLES (COUNTY CLERK)
OFFICE USE ONLY (total fees collected indicated certifies this form as a valid registration)
REGISTRATION FEE
CREDIT LEASE FEE
TRANSACTION FEE ISSUANCE FEE TITLE FEE TOTAL TAX COLLECTED
COMPUTATION OF
SALES TAX USE TAX
SALES OR USE TAX LOCAL RATE ADDITIONAL TAX COLLECTED IN STATE OF COUNTY WHEEL TAX CITY WHEEL TAX
*SERVICE OPT FEE
RV-F1315201
RDA-692
ORGAN DONOR POSTAGE VER ID / RESIDENCY VERIFICATION *TOTAL FEES COLLECTED
