TENNESSEE DEPARTMENT OF REVENUETAXPAYER AND VEHICLE SERVICES DIVISIONMULTI·PURPOSE APPLICATION

~BMIT TO CLEf?ICWiTH- $3,OQ3-EE

NEW OR CURRENT TITLE NUMBER REGISTRATION ON!. Y NUMBf:R

OWNeR INFORMATION "LEGAL STAniS: 1 (ANDl2(OR) [J ENTER NAME CODE IN BOX 1 (SAI\lE) 2IDICFERENT) 3 (MULTIPLE LAST NAMES).l (COMPANY! 5 (OVER 25 CHNMCTERS) [J MAO[J 1Lt.'[JLAST NAME FIRST NAME MIDDLE INITIAL LAST NAME FIRST NAME MIDDLE INITIAL

ADDRESS 1 (MAILING) ADDRESS 2 (PHYSICAL) CITY STATE ZIP CODE

CITY STATE ZIP CGDE ADDITIONAL OWNER

G"1Y 01' RE$'nE:NCFiPRINCIPAC "U$ OR "'CO",., I'OCMION , PURCHASE DATE ,[J D , TELEPHONE # ,'PLACARD I HEARING IMPAIRED CLSIYR I"NSURANCE POLICY #'LEASED ' SERVICE OPTIONS

SEE REVERSE $IOE FOR ItJSTRucnON5

••..• ,""" •••.•..t"" '-'H'~'·,..,.' ' .•..•,"VIN MAKE MODEL YEAR BODY TITLE BRAND --lis! the appropriate code 'ODE TYPE OF FUEL - list the appropriate CODE

(N)NEW {1) RECONSTRUCTED VE.HICLE code(U) USED (2) FLOOD DAMAGE GAS (1) ELECTRIC/HYBRID (3)(D) DEMO (J} SPECIALLY CONSTRUCTED DIESEL (2) PROPANEi418' PARTS ONLY

SURRENDERED TITLE # STATE I PREVIOUS STATES TITLED VEHICLE USE VEHICLE TYPE CURRENT MILEAGE I ODOMETER ACTUAL iO, NOT ACTuAl '" CODEINDICATOR OVER 10 YRS{ 16.000 LBS i1)(Ltst one) IN EXCESS OF MECH}\NICAL UMlTS {!II

COLOR CODE (enter appropriate COde)', MOBILE HOME , #AXLES , GROSS VEHICLE WEIGHT 'VEHICLE TRADE·IN DESCRIPTION , COMPANY VEHICLE #UPPER LOWER LGTH WDTH

PLATE INFORMATION' [requlreu for Title and Reqtstratlon and Replstratlon Only Transaction-s) SEE REVERSE SIDE FOR COMPLETr:.iNSTRUCT10NS

PLAIE #11) CITY STICKER # P) (2) 'PLATE # (TRADE IN) (2) CLASS CODEIISSUE YR (2) EXPIRATION DATE (1) (2~ (3)

TOS STICKER # (4) USDOT i REGI$'TRANT ~ (7)

_'_n .. ,. _"" .. ,' __,..... _.. ,~LIEN CODe I FIRST LIENHOLDER I LIEN DATE

STREET CITY STATE ZIP CODE

LIEN CODE I SECOND LIENHOLDER I LIEN DATE

STREET CITY STATE ZIP CODE

'j.ESSEE, REGISTRANT INfORMMION j01VNEiR OF PLATE) LEGAL -ST.,c)TUS [J NAMECODE [J M.AO [J IkU [JNAME I NAME

ADDRESS CITY STATE ZIP CODE

VEHICLE COST j TAX INFORMr,TIQN ·(required for Title & Reqlstratton Transactlonst

DEALER NAME I DEALER#

SALE PRICE , TRADE IN ALLOWANCE

[J LOST [J

, SA LEST AX PAID , 'TAX EXEMPTION REASON I SALES TAX #

r Required for Duplicate Title - T.e.A. 55.3.115

STOLEN MUTILATED RTN'D DUE TO NON DELIVERY [J ALTERED [J ILLEGIBLE

Under penalties of perjury, I hereby certify all information provided is true and correct to the best of my knowledge, and acknowledge that it is not the responsibility of the Motor Vehicle Divisionor its assignees to determine the accuracy of the information provided by me or on my behalf.

SIGNATURE OF CERTIFIER iOWNER I POWER OF ATTORNEYiAUTHORIZED SIGNATURE (IF APPLICABLE) I DATE

fNVO'CE NUMBER 1 COUNTY NAME I I 1 -----,,-,--,-:,-_-::-_--,-.,-::--:--:---::::---:-:-:--;- --::-:-===,-.,- _OFFICE USE ONLY (total fees collected indicated certifies this form as 2 valid registration)

CO NUMBER DATE Or- APPLICATION BY AUTHORITY OF REGISTRAR OF MOTOR VEHICLES (COUNTY CLERK)

RFCISTRAlION,"E I elmm 1 tEASE''' --I TRANSACTION"E I ISSUANCHEF ----,mtEFEC'-· TTOTAL'AXCOtLECTED

SAlE.'> OR lISE lAX ,LOCAL RATE , AOO''''ONALTAX COlLECfED!N 81 ATE Or COUNII' WHEEL TAl( elf)' WHEEL 1 AXCOMPVTAllGN OF

DS.'\LE-S TAX DUSE TAX'Sf.·RVICE 01'1 fEE QRGM, oceon 1 POSTAGE 1 VER 1 In i "ESIOENer VER"'CAno" 'TOTAL FEES COLLECTED

SF·13S7 RDA-692

APPLICATION FOR TITLE AND REGISTRATIONPLEASE READ INSTRUCTIONS CAREFULLY BEFORE COMPLETING THIS APPLICATION. FAILURE TO PROVIDE ALLINFORMATION MAY RESULT IN YOUR APPLICATION BEING RETURNED.

Upon completing this form for a change of address, contact the County Clerk's Office in your County of Residence, forinstructions on how to properly submit your request.Anderson County ClerkRoom 111, Courthouse100 Main St.Clinton TN 37716

Bedford County Clerk104 North Side SquareShelbyville TN 37160

Benton County Clerk1 E. Court Square, Ste. 101Camden TN 38320

Bledsoe County Clerk116 Main St.P.O. Box 212Pikeville TN 37367

Blount County Clerk345 Court St.Maryville TN 37804

Bradley County Clerk155 N. Ocoee St.P.O. Box 46Cleveland TN 37364·0046

Campbell County Clerk195 Kentucky St., Ste. 2P.O. Box450Jacksboro TN 37757

Cannon County ClerkPublic Square, CourthouseWoodbury TN 37190

Carroll County Clerk625 High St., Suite 103Huntingdon TN 38344

Carter County Cterk801 East Elk Ave.CourthouseElizabethton TN 37643

Cheatham County Clerk246 South Main St., Ste. 108Ashland City TN 37015

Chester County ClerkP.O. Box 205Henderson TN 37340

Ctaiborne County CterkP.O. Box 173Tazewell TN 37879

Clay County Cterk139 E. Lake Ave., Ste. EP.O. Box 218Celina TN 38551

Cocke County Cterk111 Court Ave., Room 101Newport TN 37821

Coffee County Clerk1327 McArthur St.Manchester TN 37355

Crockett County Clerk1 S. Bell St., Ste. 1Alamo TN 38001

Cumberland County Cterk2 North Main, Suite 206Crossville TN 38555-4583

Davidson County Clerk700 Second Ave. SouthNashville TN 37210

Decatur County ClerkP.O. Box 488Decaturville TN 38329Dekalb County Clerk1 Public Square, Room 205Smithville TN 37166

Dickson County ClerkP.O. Box 220Charlotte TN 37036

Dyer County Clerk Jackson County Clerk Moore County ClerkP.O. Box 1360 101 E. Hull 196 Main StreetDyersburg TN 38024 P.O. Box 346 P.O. Box 206

Gainesboro TN 38562 Lynchburg TN 37352

Fayette County ClerkP.O. Box 218 Jefferson County Clerk Morgan County ClerkSomerville TN 38068 214 W. Main Street P.O. Box 301

P.O. Box 710 Wartburg TN 37887

Fentress County Clerk Dandridge TN 37725-0710

101 Main Street South Obion County ClerkP.O. Box 823 Johnson County Clerk 2 Bill Burnett CircleJamestown TN 38556 222 Main Street Union City TN 38261

Mountain City TN 37683

Franklin County Clerk Overton County Clerk1 South Jefferson St. Knox County Clerk 317 E. University St., Rm. 22Winchester TN 37398 P.O. Box 1566 Livingston TN 38570

Knoxville TN 37901

Gibson County Clerk Perry County ClerkP.O. Box 228 Lake County Clerk P.O. Box 58Trenton TN 38382 116 S. Court Street Linden TN 37096

Tiptonville TN 38079

Giles County Clerk Pickett County ClerkP.O. Box 678 Lauderdale County Clerk 1 Courthouse SquarePulaski TN 38478 100 Court Square Suite 201

Ripley TN 38063 Byrdstown TN 38549

Grainger County ClerkP.O. Box 116 Lawrence County Clerk Polk County ClerkRutledge TN 37861 240 West Gaines St., NBU2 Highway411

Lawrenceburg TN 38464 P.O. Box 158

Greene County Clerk Benton TN 37307

County Courthouse Annex Lewis County Clerk204 N. Cutler St., Ste. 200 110 N. Park Ave., Room 105 Putnam County ClerkGreenville TN 37745 Hohenwald TN 38462 29 N. Washington Avenue

P.O. Box 220

Grundy County Clerk Lincoln County Clerk Cookeville TN 38503

Courthouse Circle Room 102P.O. Box 215 112 Main Avenue South Rhea County ClerkAltamont TN 37301 Fayetteville TN 37334 375 Church Street, Suite 101

Dayton TN 37321

Hamblen County Clerk Loudon County Clerk511 West 2nd North Street 101 Mulberry St., Suite 200 Roane County ClerkMorristown TN 37814 Loudon TN 37774 P.O. Box 546

Kingston TN 37763

Hamilton County Clerk McMinn County ClerkP.O. Box 24868 Suite A, 5 South Hill Street Robertson County ClerkChattanooga TN 37422-4868 Athens TN 37303 511 South Brown Street

Springfield TN 37172

Hancock County Clerk McNairy County ClerkP.O. Box 575 170W. Court Rutherford County ClerkSneedville TN 37869 Room 102 319 North Maple St., Ste. 121

Selmer TN 38375 Murfreesboro TN 37130

Hardeman County Clerk100 North Main Macoo County Clerk Scott County ClerkBolivar TN 38008 Room 104, County Courthouse P.O. Box 87

Public Square Huntsville TN 37756

Hardin County Clerk Lafayette TN 37083

465 Main Street, Courthouse Seguatchie County ClerkSavannah TN 38372 Madison County Clerk 22 Cherry Street

100 Main Street, Room 105 P.O. Box 248

Hawkins County Clerk Jackson TN 38301 Dunlap TN 37327

P.O. Box 790Rogersville TN 37857 Marion County Clerk Sevier County Clerk

24 Courthouse Square, Rm 101 125 Court Ave., Ste. 202 East

Haywood County Clerk P.O. Box 789 Sevierville TN 37862

1 North Washington Street Jasper TN 3734 7Shelby County Clerk

Brownsville TN 38012 150 Washington AvenueMarshall Coynty Clerk1107 Courthouse Annex Memphis TN 38103-1800

Henderson County Clerk Lewisburg TN 3709117 Monroe Ave .. Suite 2 Smith County ClerkLexington TN 38351-2183 Suite 101

Maurv County Clerk 122 Turner High CircleHenry County Clerk Hunter-Matthews Bldg .. #10 Carthage TN 37030101 W. Washington St., Ste. Public Square

102 Columbia TN 38401Stewart County Clerk

P.O. Box 24 P.O. Box 67Paris TN 38242 Meigs County Clerk Dover TN 37058

Main Street, CourthouseHickman County Clerk P.O. Box 218114 North Central Ave., Suite 202 Decatur TN 37322 Sullivan County Clerk

Centerville TN 37033 3258 Hwy. 126, Suite 101Blountville TN 37617

Monroe County CterkHouatnn County Clerk 103 College StreetP.O. Box 388 Madisonville TN 37354 Sumner County Clerk

Erin TN 37061 355 North Belvedere, Room 111Gallatin TN 37066-5410

Montgomery County ClerkHumphreys County Clerk 350 Pageant Lane, Suite 502Room 2, Courthouse Annex Clarksville TN 37040 Tipton County Clerk

Waverly TN 37185 220 Hwy. 51 North, Suite 2P.O. Box 528Covington TN 38019

Trousdate County Clerk200 E. Main St., Room 2Hartsville TN 37074-1706

Unicoi County ClerkP.O. Box 340Erwin TN 37650

Union County Clerk901 Main Street, Ste. 119Maynardville TN 37807

Van Buren County ClerkAdministrative Bldg., Smith St.P.O. Box 827Spencer TN 38585

Warren County Clerk201 Locust StreetMcMinnville TN 37110

WaShington County ClerkP.O. Box 218Jonesborough TN 37659

Wayne County ClerkBox 367Waynesboro TN 38485

Weakley County ClerkP.O. Box 587Dresden TN 38225

White County Clerk1 East Bockman WaySparta TN 38583

Williamson County Clerk1320 W. Main, Suite 135P. O. Box 624Franklin TN 37065

Wilson County Clerk228 E. Main, Room 101P.O. Box 950Lebanon TN 37088-0950