Form Dmv 1 Irp – Fill Out and Use This PDF

	DMV-1-IRP				STATE OF WEST VIRGINIA
	Rev. 05/2010				DIVISION OF MOTOR VEHICLES
					MOTOR CARRIER SERVICES
	FOR DEPARTMENT USE ONLY
					CHARLESTON 25317
	CLASS BA:			Application for a Certiicate of Title for a Motor Vehicle
					TYPE OR PRINT IN BLUE OR BLACK INK
				MAKE CHECKS PAYABLE TO DIVISION OF MOTOR VEHICLES

The owner(s) of the following vehicle make application for a certiicate of title for that vehicle and for that purpose state the following:

Number

Street

City or Town

County

State

Zip Code

VEHICLE DESCRIPTION

MAKE

YEAR

V. I. N.

STYLE OF BODY

TRUCKS Requested (GVW)

WEIGHT

Title Brands:

SALVAGE

RECONSTRUCTED

OTHER:

Purchase Price $

Trade-in $

Net Cost $

5% Sales Tax

(Credit allowed only on vehicles registered in West Virginia and the tax paid thereon by applicant)

TRADE-IN DESCRIPTION

1)

MAKE

YEAR

SERIAL NO.

WEST VIRGINIA TITLE NUMBER

LIENS AND ENCUMBRANCES

1

Name

Amount

Mailing

Address

Kind of Lien

Date

Street

City

State

Zip Code

C/S/C

D/T

S/A

2

Name

Amount

Mailing

Address

Kind of Lien

Date

Street

City

State

Zip Code

C/S/C

D/T

S/A

I hereby state that there is a motor vehicle liability policy in effect on the described vehicle in accordance with the provisions of the West Virginia Motor Vehicle Laws and certify that the statements made are true and correct to the best of my knowledge and belief under penalty of false swearing. West Virginia Motor Vehicle Law § 17A-9-1 : Fraudulent Applications.

Effective date of insurance policy: From

To

TITLE APPLICATION MUST BE SIGNED BY OWNER

If Title reads “AND” Both Signatures of Owners Must Appear

Name of Insurance Company

Name of Insurance Agent

OWNER’S SIGNATURE

Insurance Policy Number

OWNER’S SIGNATURE

INSURANCE MUST BE IN EFFECT WHEN APPLICATION RECEIVED.

DEALER CERTIFICATION

on

This is to certify that the above described vehicle was acquired from

month

day

year

and sold to the above named purchaser on month

day

year

.

The undersigned dealer further Certiies that the sale price, trade-in and net cost are true and correct and that the Federal Odometer Regulation has been satisied. Federal Regulations Require you to State the Odometer Mileage Upon Transfer of Ownership.

I certify to the best of my knowledge that the odometer reading isand relects the actual mileage of the vehicle unless one of the following statements is checked:

1. Mileage stated is in excess of its mechanical limits.

2. The odometer reading is not the actual mileage - WARNING-ODOMETER DISCREPANCY.

Dealer Name

Address Signature (X)

Dealer Number

Any check that is not honored for payment will result in a $10.00 service charge.

Be certain you have completed the application, including your signature.

If the vehicle is titled in another state, the title must accompany this application.

All titles with liens are mailed directly to the lienholder.

Be sure to include your Zip Code and Zip Code of lienholder.

Statement of insurance must be submitted with each application for motor vehicle registration.

FEES

$10.00 for title	$
$5.00 for lien	$
5% Sales Tax (Over 55,000 lbs. Exempt)	$
TOTAL	$

*Credit on trade-in allowed only for vehicles registered in West Virginia and taxes paid thereon by applicant. For additional information call 304-558-4448, 304-558-3629, or toll-free 1-800-642-9066

Mail to:

Motor Carrier Services

Division of Motor Vehicles

PO Box 17900

Charleston, West Virginia 25317