OHIO DEPARTMENT OF PUBLIC SAFETY BUREAU OF MOTOR VEHICLES APPLICATION FOR DEALER ASSIGNMENT POWER OF ATTORNEY TO TRANSFER OWNERSHIP AND ATTESTATION OF MILEAGE AND IDENTITY FOR THE TRANSFER OF OWNERSHIP OF A VEHICLE OR WATERCRAFT TO OR FROM A MOTOR VEHICLE OR WATERCRAFT DEALER LICENSED BY CHAPTERS 4517/1547 PURSUANT TO OHIO REVISED CODE 4505.0323/1548.032 AND APPLICATION FOR CERTIFICATE OF TITLE. ASSIGNMENT OF OWNERSHIP for the price of $ I (we) certify the vehicle or watercraft or outboard motor described in this statement was delivered on Is Seller a Minor? TRANSFEREE’S / BUYER’S PRINTED ADDRESS to: TRANSFEREE’S / BUYER’S PRINTED NAME Yes No Warning to transferor and transferee (seller and buyer). You are required by law to state the true selling price. A false statement is in violation of section 2921.13 of the Ohio Revised Code and is punishable by six months imprisonment and a fine of up to one thousand dollars or both. All transfers are audited by the 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. PICTURE ID ISSUED FROM STATE OF OPERATOR LICENSE NUMBER OR ID NUMBER CURRENT TITLED OWNER(S) NAME CONTROL NUMBER YEAR MAKE TITLE NUMBER HP CURRENT TITLE TYPE REGULAR SALVAGE OFF ROAD VIN/WIN/MIN MODEL BODY TYPE LENGTH THIS VEHICLE WAS A (IF APPLICABLE) FORMER LAW ENFORCEMENT FORMER TAXI FLOOD VEHICLE Federal and State laws require that you state the mileage in connection with transfer of ownership. Failure to complete or providing false information may result in fines and/or imprisonment. I (we) certify to the best of my (our) knowledge that the odometer now reads and is the actual mileage of the vehicle unless one of the following statements is checked. The mileage stated is in excess of the mechanical limits. , NO TENTHS MILES The odometer reading is not the actual mileage. WARNING–ODOMETER DISCREPANCY APPLICATION FOR CERTIFICATE OF TITLE (Type or Print in Ink) Fee of $5.00 for failure to apply for title within 30 days of assignment. CHECK TYPE OF APPLICATION(S): MOTOR VEHICLE MEMORANDUM WATERCRAFT DUPLICATE (Check One) OUTBOARD MOTOR SALVAGE REPLACEMENT Lost Stolen Destroyed APPLICANT’S PRINTED NAME SSN/EIN APPLICANT’S PRINTED STREET ADDRESS PURCHASE PRICE $ TAX PAID $ VENDOR’S NUMBER CITY ZIP CODE COUNTY TRADE IN ALLOWANCE GROSS TAX DUE VENDOR’S DISCOUNT $ $ $ TAX EXEMPTION: YES DEALER’S PERMIT NUMBER REASON CONDITION OF VEHICLE OR WATERCRAFT OR OUTBOARD MOTOR (CHECK ONLY ONE): GOOD FAIR POOR WRECKED LIEN INFORMATION: If no lien, state “none”. If more than one lien, attach statement of all additional liens. LIENHOLDER PRINTED NAME/E CODE # ADDRESS CITY I (we) state that all information contained in this application is true and correct. APPLICANT’S SIGNATURE STATE IS APPLICANT A MINOR? PRINTED X ZIP CODE YES NO NON PRINTED TRANSFEREE’S / BUYER’S ACKNOWLEDGEMENT OF ABOVE ODOMETER CERTIFICATION AND/OR DUPLICATE TRANSACTIONS TRANSFEREE’S / BUYER’S OR APPLICANT’S PRINTED NAME TRANSFEREE’S / BUYER’S SIGNATURE X I/We, the current titled owner or applicant, appoint as my true and lawful attorney-in-fact to execute any and all application for assignment of Certificate of Title for the motor vehicle listed above. I attest to the above odometer reading. I warrant the title to be free of all liens. TRANSFEROR’S / SELLER’S PRINTED NAME TRANSFEROR’S / SELLER’S SIGNATURE TRANSFEROR’S / SELLER’S PRINTED ADDRESS CITY X STATE ZIP CODE NOTE: All blank spaces above must be completed before acknowledgement. If not applicable, insert NA or NONE in the space provided. Sworn to and subscribed in my presence by this day of yr . My commission expires (seal) BMV 3772 3/11 year X CLERK, DEPUTY CLERK OF COURTS NOTARY . X WITNESS BY DEALER OR SALESPERSON American LegalNet, Inc. www.FormsWorkFlow.com