TENNESSEE DEPARTMENT OF REVENUE
VEHICLE SERVICES DIVISION
DUPLICATE TITLE
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 25 CHARACTERS
LAST NAME
FIRST NAME
MIDDLE INITIAL
ADDRESS 1 (MAILING) ADDRESS 2 (PHYSICAL)
LAST NAME
FIRST NAME
MIDDLE INITIAL
CITY
STATE
ZIP CODE
CITY
STATE
ZIP CODE ADDITIONAL OWNER
CNTY OF RESIDENCE/PRINCIPAL BUS OR INCORP LOCATION
PURCHASE DATE
MAO
ILU
*LEASED
*SERVICE OPTIONS
TELEPHONE #
PLACARD/HEARUNG IMPAIRED CLS/YR *INSURANCE POLICY #
VEHICLE INFORMATION
VIN
MAKE
YEAR
BODYMODEL
LIEN INFORMATION (if lien present)
STREET
STREET
FIRST LIENHOLDER
SECOND LIENHOLDER
CITY
STATE
ZIP CODE
CITY
STATE
ZIP CODE
LIEN DATE
LIEN DATE
LESSEE/REGISTRANT INFORMATION (OWNER OF PLATE)
LEGAL STATUS
NAME CODE MAO ILU
NAME
NAME
ADDRESS
CITY
STATE
ZIP CODE
*Required for Duplicate Title - T.C.A. 55-3-115 (submit illegible or altered Certificate of Title)
LOST
STOLEN MUTILATED RETURNED 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 Vehicle Services 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)
RV-F1321801
X
OFFICE USE ONLY
LIEN CODE
LIEN CODE
