Form Tr 212A – Fill Out and Use This PDF

County Name

County No.

County Situs

Application Date

TRANSACTION TYPE:

*VEHICLE TYPE:

REGISTRATION TYPE:

* Code for: Salvage/Rebuilt Salvage:

Nonhighway/Formerly Nonhighway:

Plate Number

Decal Number

Legal Type

Reg. Expires

Tax Unit

Class Code

ACQUISITION CODE:

OWNER’S NAME(S) (Last, First, Middle Initial)

Relationship Code

Address

City

State

ZIP

VIN:

Year:

Make:

Model:

Style:

Purchase/Brought into KS Date:

Mileage:

. Ø

Actual

Exceeds

Not Actual

Exempt

Empty Wght.:

Gross Wght.:

Truck Class:

Local Base Point:

New Gross Wght. & Truck Class:

(<Use on truck/trailer wght. change) Registration Mileage:

SPECIAL MAIL OUT

Temporary (Mail just the title.)

Permanent (Mail title & renewal notice.)

Lienholder (Mail title to lienholder.)

Name:

Address

City

State

ZIP

1ST LIENHOLDER’S

2ND LIENHOLDER’S

NAME

NAME

Address, City

Address, City

State, ZIP

State, ZIP

T

1ST TOD

2ND TOD

NAME

NAME

O

D

Address, City

Address, City

State, ZIP

State, ZIP

PLATE TRANSFER INFORMATION

FEE SUMMARY

Previous Vehicle’s VIN:

Title Fee

Penalty

Year:

Make:

Style:

Registration Fee

Vehicle Sold to/Repossessed by:

................................

.........................................Penalty

ADDING NAME(s) Relationship:

Parent

Spouse

Child

..........................................Decal Fee

Signature of Person(s)

.............................................TOTAL

Being Added:

.....................Reflectorized Plate Fee

Insurance Policy No.:

Total

Property/Tax Due

Insurance Co. Name:

Penalty

I hereby certify that I am a resident or have a bona fide place of business in this county and that

I am an owner of and have in effect financial security for the aforementioned vehicle as required

........Previous Prop./RV Tax Due

by Kansas law. I further certify that all liens and/or encumbrances, if any, are listed and the

Prev. Prop./RV Tax Penalty

information on this application is true and correct to the best of my knowledge and belief.

Total

FALSE CERTIFICATION CAN RESULT IN CRIMINAL PROSECUTION

Owner’s Signature(s)

Sales Tax

County Miscellaneous Fee

GRAND TOTAL

Date

TR-212A (09/01)