Tom Orlando Lorain County Clerk of Courts Applicant's Name Applicant's Address APPLICATION FOR CERTIFICATE OF TITLE TO A MOTOR VEHICLE Type or Print in Ink Check the Type of Application(s) SSN or EIN County Applicant hereby declares under penalty of perjury that he/she is the lawful of the following described motor vehicle and hereby makes application(s) for the following: (owner / purchaser / lienholder) ORIGINAL CERTIFICATE OF TITLE: Applicant acquired this motor vehicle from previous owner: Previous owner's Address: Dealer Permit # Evidence of Ownership MCO, Previous Title No. Registration, etc. Vendor # The following is a full statement of all liens on this motor vehicle. If none state "None" If more than One, attach a statement of all additional liens. Lienholder /E Code# Address DUPLICATE CERTIFICATE OF TITLE: Odometer reading required. has been lost, stolen or destroyed residing at Applicant states that Certificate of Title Number and that the motor vehicle has not been sold or disposed of except as stated below. The vehicle is in the possession of and that if the Certificate of Title is hereafter recovered by the applicant he/she will deliver the Title to the Lorain County Clerk of Courts for cancellation. CURRENT ODOMETER READING IS thousands , hundreds . X REPLACEMENT CERTIFICATE OF TITLE for certificate of Title Number MEMORANDUM CERTIFICATE OF TITLE for certificate of Title Number SALVAGE CERTIFICATE OF TITLE: Certificate of Title Number Applicant states that the original Certificate of Title has been surrendered to the Clerk of Courts Year Vehicle Condition (check only one) Make Model Body Type VIN Good Fair Poor Wrecked WARNING: You are required by law to state the true selling price. A false statement is in violation of sec. 2921.13 O.R.C. and is punishable by up to six months imprisonment and a fine of up to one thousand dollars or both. All transfers are audited by the Ohio Department of Taxation. The seller and buyer must provide any information requested by the Department of Taxation. The buyer may be assessed any additional tax found to be due. Purchase Price $ Trade In Amount $ Sales credit Amount $ Tax Exemption: Is applicant a minor? Applicant's Signature Sworn to and subscribed in my presence by Clerk, Deputy Clerk - Notary (SEAL) My commission expires , 20 $ this day of Gross Tax $ Net Tax 20 Yes Yes Reason No AN ADDITIONAL FEE OF $5.00 IS REQUIRED FOR FAILURE TO APPLY FOR A TITLE WITHIN 30 DAYSOF ASSIGNMENT. American LegalNet, Inc. www.FormsWorkFlow.com