TENNESSEE DEPARTMENT OF REVENUE
TAXPAYER AND VEHICLE SERVICES DIVISION
MULTI-PURPOSE APPLICATION
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
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
SEE REVERSE SIDE FOR INSTRUCTIONS
TELEPHONE #
PLACARD/HEARUNG IMPAIRED CLS/YR *INSURANCE POLICY #
VEHICLE INFORMATION
VIN
MAKE
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
CODE
TYPE OF FUEL - list the appropriate code
GAS (1) ELECTRIC/HYBRID (3)
DIESEL (2) PROPANE (4)
CODE
SURRENDERED TITLE #
MODEL
STATE
PREVIOUS STATES TITLED VEHICLE USE VEHICLE TYPE CURRENT MILEAGE
ODOMETER ACTUAL (0) NOT ACTUAL (3)
INDICATOR OVER 10 YRS/16,000 LBS. (1)
(List one) IN EXCESS OF MECHANICAL LIMITS (9)
CODE
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/ISSUE YR(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) TEMP OPERATOR PERMIT # (3)
# OF SEATS (5)
ZONE COUNTY NAME (6)
USDOT/REGISTRANT #(7) MOTOR CARRIER #(8)
LIEN INFORMATION (if lien present)
LIEN CODE
LIEN CODE
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
VEHICLE COST/TAX INFORMATION *(required for Title and Registation Transactions)
SALE PRICE
TRADE IN ALLOWANCE
TAXABLE AMOUNT
SALES TAX 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 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 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 REGISTRAT OF MOTOR VEHICLES (COUNTY CLERK)
OFFICE USE ONLY
REGISTRATION FEE
COMPUTATION OF
SALES TAX
USE TAX
CREDIT
LEASE FEE
TRANSACTION FEE
ISSUANCE FEE
TITLE FEE
TOTAL TAX COLLECTED
SALES OR USE TAX
LOCAL RATE
ADDITIONAL TAX
COLLECTED IN STATE OF
COUNTY WHEEL TAX CITY WHEEL TAX
*SERVICE OPT FEE
ORGAN DONER
POSTAGE VER ID/RESIDENCY VERIFICATION
*TOTAL FEES COLLECTED
RV-F1315201
