Dmv 4 Tr Form – Fill Out and Use This PDF

DMV-4-TR

REV 7/12

West Virginia Department of Transportation

Division of Motor Vehicles

Affidavit of Duplicate Title for a Vehicle or Watercraft

MAIL TO: Receiving and Processing • PO Box 17710 • Charleston, WV 25317 • 1-800-642-9066 • www.dmv.wv.gov

PRINT IN BLUE OR BLACK INK ONLY. THIS APPLICATION MUST BE ACCOMPANIED BY A COPY OFTHE OWNER’S DRIVER’S LICENSE. ENCLOSE A COPY OF YOUR REGISTRATION CARD IF AVAILABLE. IF LOSTTITLE SHOWED A LIEN RELEASE, SECTION D MUST BE COMPLETED. THERE IS A $10.00 FEE FOR YOUR DUPLICATETITLE.

Vehicle Title

Select Reason for Requesting Duplicate (Check Only One):

Lost

Destroyed

Never Received

Boat Title

Defaced (attach defaced title)

Change of Address

A.) Owner(s) Information

B.) Vehicle/Watercraft Information

Name

Make

Year

VIN or

OWNER(S) NAME(S)

Address

Hull No

Plate or

Reg. No

CITY

STATE

ZIP

Body Style or

Hull Material

C.) Owner/Applicant Certi

The undersigned applicant, being duly sworn upon oath, deposes and says they are the owner of the vehicle/watercraft described herein:

I, the undersigned, swear or affirm that the information we/I have entered on this form is correct. I understand that making a false statement on this form may constitute the crime of perjury. Furthermore, I agree to indemnify and hold harmless, the West Virginia Division of Motor Vehicles from any liability arising from this transaction. I understand that the penalty for false statement in this application holds a fine of not more than $100.00 or imprisonment in the county jail for thirty days, or both.

This application must be signed by the owner(s). If a person other than the applicant is signing this application, a power of attorney form is required.

If the title reads “AND”, both owners signatures MUST appear. If signing for a company, indicate your title or position.

(X)		(X)
	SIGNATURE OF APPLICANT OR LEGAL REPRESENTATIVE		SIGNATURE OF APPLICANT OR LEGAL REPRESENTATIVE

D.) Discharge of Lien Holder(s)

If the vehicle or watercraft has EVER had a lien against it, section D MUST be completed by the lien holder before a clear title can be

issued. If section D is not completed, the title will be mailed directly to the lien holder on record.

The undersigned, being a duly authorized agent for the lien holder, deposes upon his oath and says that the lien is discharged and the lien holder has no interest in the above vehicle/watercraft.

Name of Lien Holder

Address

(X)

SIGNATURE OF OFFICER

TITLE

This lien is fully paid, satis

day of

, 20

.

(X)

/

/

SIGNATURE OF NOTARY

COMMISSION EXPIRATION DATE

E.) Release A

I,

hereby authorize

to receive my duplicate title.

VEHICLE OR WATERCRAFT OWNER

NAME OF DEALERSHIP, LIEN HOLDER, OR INDIVIDUAL

(X)

SIGNATURE OF OWNER

DIVISION USE ONLY • Veriied in Computer: