John J. Barthelmes
Commissioner of Safety
STATE OF NEW HAMPSHIRE
DEPARTMENT OF SAFETY
DIVISION OF MOTOR VEHICLES
BUREAU OF TITLE AND ANTI-THEFT
23 Hazen Drive, Concord, NH 03305
TDD Access: Relay NH 1-800-735-2964
LICENSE #:
Richard C. Bailey, Jr.
Director of Motor Vehicles
APPLICATION FOR DUPLICATE CERTIFICATE OF TITLE
I hereby make application, in accordance with the New Hampshire laws for the issuance of a duplicate certificate of title to the below described vehicle. The
original certificate has been (check one).
STOLEN
LOST DESTROYED MUTILATED BECOME ILLEGIBLE NEVER RECEIVED
PLEASE GIVE THE CURRENT MAILING ADDRESS IN BLOCK 1.
1. OWNER'S NAME(S)(LAST,FIRST,MIDDLE) 2. DATE(S) OF BIRTH
MO/DAY/YR
STREET OR R.F.D. NO.
PER APPLICATION $25.00
MAKE CHECK PAYABLE TO:
STATE OF NH - DMV
A.
B.
CITY OR TOWN STATE ZIP CODE
DO NOT TYPE IN THIS SPACE
3. LEGAL RESIDENCE IF OTHER THAN MAILING ADDRESS
APPROVED BY
SUSPENDED BY
4. VEHICLE IDENTIFICATION NUMBER 5. ODOMETER-ACTUAL MILEAGE
6. MAKE OF VEHICLE 7. MODEL NAME OR NUMBER 8. BODY TYPE 9. VEHICLE COLOR(S)
10. YR. OF MFG. 11. MODEL YR. 12. NO. OF CYLINDERS 13. GROSS WEIGHT 14. AXLES 15. PREVIOUS TITLE NO. 16. STATE
THIS VEHICLE IS SUBJECT TO THE FOLLOWING LIENS:
17. FIRST LIEN HOLDER'S NAME (IF NONE, TYPE NONE)
MOTOR VEHICLE
USE ONLY
ADDRESS
CITY OR TOWN STATE ZIP CODE
18. SECOND LIEN HOLDER'S NAME & ADDRESS
OWNER’S SIGNATURE(S):
19. OWNER'S SIGNATURE(S) OR LIENHOLDER READ PENALTY BELOW BEFORE SIGNING 20. DATE SIGNED (MO/DAY/YR)
X X
IF THE OWNER IS A CORPORATION, PARTNERSHIP OR OTHER ASSOCIATION, THE PERSON SIGNING ON ITEM 19 MUST CERTIFY BELOW, UNDER PENALTY OF
PERJURY, THAT HE/SHE IS AUTHORIZED TO SIGN ON BEHALF OF THE OWNER.
I,
HEREBY CERTIFY THAT I AM AN AGENT AUTHORIZED TO SIGN THIS APPLICATION ON BEHALF
SIGNATURE
OF
, THE OWNER NAMED IN ITEM 1
SUBSCRIBED AND SWORN TO BEFORE ME AT
N.H. ON THE
DAY OF
YR.
NOTARY PUBLIC/JUSTICE OF THE PEACE
AUTHORIZATION FOR MAILING:
I/WE HEREBY CERTIFY THAT I/WE INTEND TO TRANSFER MY/OUR INTEREST IN THE ABOVE VEHICLE TO A N.H. LICENSED DEALER (FOR N.H. DEALERS ONLY).
I/WE AUTHORIZE THE DIVISION OF MOTOR VEHICLES TO FORWARD THE N.H. CERTIFICATE OF TITLE ISSUED AS A RESULT OF THIS APPLICATION TO THE DEALER
NAMED BELOW (SEE REVERSE SIDE “INSTRUCTIONS” #5). THIS SECTION NOT FOR USE BY DEALERS OUTSIDE OF N.H. OR FOR PRIVATE SALES.
21. N. H. DEALER ‘S NAME: ADDRESS: DLR PLATE #:
OWNER’S SIGNATURE(S) FOR AUTHORIZATION FOR MAILING ONLY:
22. OWNER'S SIGNATURE(S) READ PENALTY BELOW BEFORE SIGNING 23. DATE SIGNED (MO/DAY/YR)
X X
PENALTY
A PERSON WHO, WITH FRAUDULENT INTENT, USES A FALSE OR FICTITIOUS NAME OR ADDRESS, OR MAKES A MATERIAL FALSE STATEMENT, OR FAILS TO
DISCLOSE A SECURITY INTEREST, OR CONCEALS ANY OTHER MATERIAL FACT, IN AN APPLICATION FOR A CERTIFICATE OF TITLE, OR IN ANY PROOF OR
STATEMENT IN WRITING IN CONNECTIONS THEREWITH, SHALL BE GUILTY OF A CLASS B FELONY IF A NATURAL PERSON, OR GUILTY OF A FELONY IF ANY
OTHER PERSON, RSA 262:1,I.
IF LIENHOLDER WAS NAMED ON ORIGINAL TITLE
SEE REVERSE SIDE “INSTRUCTIONS” #4
