APPLICATION FOR DUPLICATE CERTIFICATE OF OWNERSHIP STATE OF NEW JERSEY MOTOR VEHICLE COMMISSION SPECIAL SERVICES P.O. BOX 017 TRENTON, NEW JERSEY 08666-0017 (609) 292-6500 EXT. 5074 ABOVE SPACE IS FOR OFFICE USE ONLY 1. This form is to be completed by the titled owner(s). Please type or print clearly. 2. A $60.00 check or money order (Do Not Send Cash) and a copy of the current or expired registration certificate or INSTRUCTIONS- PLEASE READ CAREFULLY insurance identification card and proof of identity (copy of driver's license) must accompany the application. Mail all information to the Trenton Central Office or bring in person to any motor vehicle agency. 1. NAME OF TITLED OWNER OWNER'S NEW JERSEY DRIVER LICENSE NUMBER (IF BUSINESS-CORPCODE) DATE OF BIRTH EYE COLOR ADDRESS NO. AND STREET CITY SEX STATE ZIP CODE PHONE: (HOME) (CELL) WHERE DO YOU WANT THE TITLE MAILED (IF DIFFERENT THAN ABOVE ADDRESS)? IF CO-OWNER: 1a. NAME OF CO-OWNER NEW JERSEY DRIVER LICENSE NUMBER DATE OF BIRTH EYE COLOR SEX ADDRESS (WORK) DESCRIPTION OF VEHICLE 2. LICENSE PLATE NO. MAKE YEAR BODY TYPE MODEL WEIGHT CLASS COMPLETE VEHICLE IDENTIFICATION NO. 3. ARE THERE ANY ENCUMBRANCES OR LIENS AGAINST THE VEHICLE AT THIS PRESENT TIME? YES NO IF "YES", GIVE NAME AND ADDRESS OF LIENHOLDER NOTE: If the original certificate was issued subject to lien and lienholder has not submitted evidence of satisfaction, a duplicate certificate of ownership will not be issued until proof of payment is received from the lienholder. *If banks have merged it must be stated on Lien Release. *LIENHOLDERS MUST SUPPLY A COPY OF CONTRACT OR LEASE AGREEMENT AND (IF APPLICABLE) POWER OF ATTORNEY. R.S. 39:10-12... "A person who falsely states, in any application to the Chief Administrator for a duplicate certificate of ownership, that a certificate of ownership, or title papers, are lost, shall be subject to a fine of not less than two hundred dollars ($200.00) nor more than five hundred dollars ($500.00) or imprisonment for a term not exceeding thirty days or both." This application is submitted to the Chief Administrator of the Motor Vehicle Commission because the whereabouts of the title paper for the motor vehicle described herein- owned by the undersigned IS UNKNOWN and certification is hereby made that it IS LOST. It is further certified that the YEAR MAKE VEHICLE IDENTIFICATION NO. was physically examined by me and the identification number is as entered hereon. I certify that I have compared this number with the numbers shown on the evidence of ownership and on my application for a duplicate New Jersey Certificate of Ownership and they agree. I further certify that I have read and understand this application and that all statements are correct. DATE SIGNATURE OF TITLED OWNER DATE SIGNATURE OF CO-OWNER (IF PARTNERSHIP, SO INDICATE, IF CORPORATION, GIVE TITLE OF OFFICER) *Need POWER OF ATTORNEY if in a company name. IF NOT FILLED IN ENTIRELY AND ACCOMPANIED BY CHECK OR MONEY ORDER FOR $60.00 (DO NOT SEND CASH) AND PROOF OF IDENTITY (COPY OF DRIVER'S LICENSE) THIS APPLICATION WILL BE REJECTED. OS/SS-52 (R5/16) American LegalNet, Inc. www.FormsWorkFlow.com