CINDY CARPENTER

/ CLERK OF COURTS

APPLICATION FOR THE CERTIFICATE OF TITLE (Type or Print in ink.)

Fee of $ 5.00 for failure to apply for title within 30 days of assignment.

Check the type of application(s): * Motor Vehicle * Watercraft * Outboard Motor * Salvage * County of Residence

* Memorandum * Duplicate * Replacement * Lien ______

Certificate of Title Number: ______Control Number: ______

Applicant’s Printed name: ______SSN: ______- ______- ______

Applicant’s Address: ______Zip ______

* Lawful owner * Purchase * Lienholder

EVIDENCE OF OWNERSHIP ______MCO, MSO, Previous Title No., Registration, etc.

Applicant acquired said motor vehicle by: * Purchased * Repo * Auction * Other ______

FROM: Name of Previous Owner ______

Address of Previous Owner ______

The following is a full statement of all liens on said motor vehicle. If no lien, state ”none.” If more one lien, attach statement of all additional liens.

Lienholder: ______Address: ______

Dealer’s Permit Number: ______Vendor’s Number ______

* Tax Exempt Reason: ______

Purchase Price $ ______Trade in Amount $ ______Sales/ Use Tax $ ______

Condition of Vehicle/ Watercraft/ Outboard Motor (check one only)

* Good * Fair * Poor * Wrecked Sales Credit Amt. $ ______

YEAR ______MAKE ______MODEL ______

VIN ______BODY TYPE ______CONVERSION ______

ODOMETER CERTIFICATION

Federal and State laws require that you state the mileage in connection with transfer of ownership. Failure to complete or provide false information may result in fines and/ or imprisonment.

I (we) certify to the best my (our) knowledge that the odometer now reads and is the actual mileage of the vehicle unless one of the following states is checked: * Excess of Mechanical limits * Not actual – Odometer Discrepancy

Buyer’s Signature: ______Address: ______

Seller’s Signature: ______Address: ______

WATERCRAFT ______Serial Number/ HIN ______

Year ______Model ______Length ______feet ______inches

Motor ______Motor Serial Number ______HP ______

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 2921.12 of the Ohio Revised Code and is punishable by six months imprisonment and a fine 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.

Application’s Signature ______

Sworn to and subscribed in my presence this ______day of ______Yr. ______

Clerk, Deputy Clerk of Court – Notary ______

(Seal) FORM # CC1