STATE OF ALASKA
DIVISION OF MOTOR VEHICLES
VEHICLE TRANSACTION APPLICATION
SERIAL NUMBER (VIN): ALASKA LICENSE PLATE:
ODOMETER:
(MILES ONLY)
YEAR:
MAKE:
MODEL: BODY STYLE: COLOR:
SECONDARY SERIAL NUMBER (VIN):EMPTY WEIGHT:
Actual
Estimated
Owner of a Motor Vehicle Registered in a company name, leased from a company, used for business/commerce, or Motor Vehicles with a GVWR 10,001 pounds or more; must complete
page 2 (reverse) for PRISM/HVUT compliance.
IS THE VEHICLE USED
COMMERCIALLY
?
If yes, complete
the back of the form
“AND”
“OR”
“AND” requires the signature of all owners sell/transfer “OR” requires the signature of a single owner to sell/transfer
OWNER’S FULL LEGAL NAME/LESSEE NAME:
CO-OWNER’S FULL LEGAL NAME/LESSEE NAME:
ALASKA DL/ID #:
DOB or SSN/TIN: If no Alaska DL/ID
ALASKA DL/ID #:
DOB or SSN/TIN: If no Alaska DL/ID
MAILING ADDRESS OF OWNER OR LEASING COMPANY:
COMPANY NAME / LESSOR NAME / FAMILY TRUST: TAXPAYER ID# (TIN):
OWNER'S RESIDENCE ADDRESS OR PHYSICALL ADDRESS OF THE VEHICLE:
EMAIL ADDRESS:
(Optional)
PHONE#:
LIENHOLDER NAME: - If vehicle is paid in full mark None
NONE
LIENHOLDER MAILING ADDRESS: CITY/STATE/ZIP:
CHANGE OF OWNERSHIP
AFFIDAVIT/ADDITIONAL NOTES Was this transaction unusual? Use this area to further explain:
WILL NOT BE DRIVEN ON PUBLIC ROADS TO BE HELD IN INVENTORY CORRESPONDENCE
CITY/STATE/ZIP:
CITY/STATE/ZIP:
EXEMPTIONS: I AM APPLYING FOR...
ELIGIBLE OWNER:
ALASKA DL/ID #:
SENIOR (P TAB): I am 65 years or older
MOBILITY RELATED DISABILITY (P TAB): Requires completed Form 861, signed by a qualified provider for original issuance.
ALASKA DISABLED VETERAN (P TAB): Requires proof of Service Connected Disability Rating of 50% or more and proof of service discharge.
Z TAB: My vehicle is 8 years or older and I live in an eligible area (All trailers regardless of age are eligible)
ALASKA NATIONAL GUARD: Requires current member of the AK National Guard with valid military ID, and current Unit documentation MPF or PQR .
ACTIVE DUTY MILITARY: Requires LES issued within 90 days. Alaska resident vehicles must be located outside of Alaska to be eligible for exemption.
GOVERNMENT: Requires vehicle to be registered in the name of a government organization.
CHARITABLE: Requires proof of tax exempt status from IRS documentation.
ARE YOU AN ALASKA RESIDENT?
YES NO
DO YOU WISH TO DONATE $1 OR MORE TO SUPPORT THE ORGAN AND TISSUE DONATION PROGRAM? AMOUNT $ _______
•I certify under penalty of perjury that all information is true and correct. False statements are punishable under AS 11.56.210.
•I certify under penalty of law there is a liability insurance policy for this vehicle if required by AS 28.22.011 and this policy will be maintained during the entire
registration period.
•The address shown is my true legal address and the vehicle will be operated on Alaska roadways.
•If this is a commercial vehicle, I am familiar with and have knowledge of the Federal Motor Carrier Safety Regulations 49 CFR, Hazardous Materials Regulations
and applicable Federal/state CMV safety laws and regulations.
SIGNATURE OF APPLICANT / AGENT (INCLUDE TITLE) DATE SIGNATURE OF APPLICANT / AGENT (INCLUDE TITLE)
DATE
PLEASE UPDATE MY ORGAN DONOR STATUS
WHAT HAS MADE YOU SMILE
TODAY?
(Optional)
(Optional)
V1
( )
REV: 6/30/2021
NEEDS NEW PLATES
PLATE TRANSFER:
TITLE ONLY
YES
NO
ADD/REMOVE LIENHOLDER
OUT OF STATE TITLE
TRANSFER
REGISTER
LOST TAB
LOST PLATE OTHER:______
NOTE: Vehicles registered in a company name, used for business or
commerce are not eligible for an exemption
PLEASE UPDATE MY ORGAN DONOR STATUS
