Louisiana Vehicle Application Form – Fill Out and Use This PDF

Louisiana Department of Public Safety and Corrections

TO AVOID REJECTION:

Office of Motor Vehicles

Complete all required information

P.O. Box 64886, Baton Rouge, LA 70896-4886

TRANSFER CODE

ELECTRONIC FUND

Date Prepared

Type of Plate

VEHICLE APPLICATION

DEALER CODE

VIN

Make

License No.

Exp. Date

Body

Color

Year

Mileage

Model/Weight

Name of Owner

Driver's License or EIN

Name of Joint Owner (if applicable)

Driver's License or EIN

Owner's Principal Residence Address (or Business Location if Vehicle is Used for Commercial Purposes)

Are you

residing within the corporate limits of municipality?

YES

NO

City

Parish

State/Zip

Are you residing within a special tax district or ward?

YES

NO

If yes, what ward or district?

Lessee

Mail To

Domicile

Renter

If lessee, domicile, or renter is indicated, renewal notice

should be mailed to (check one):

Domicile Code

.

Owner

Lessee, renter, or domicile address

Name

Driver's License or EIN of Lessee or Renter

Street

Trade VIN

City

Parish

State/Zip

Trade License No.

VEHICLE IS SUBJECT TO SECURITY AGREEMENT AS FOLLOWS:

ELECTRONIC LIEN

First Lienholder's Name

Second Lienholder's Name

TRANSFER CODE

Street

Street

City/State/Zip

City/State/Zip

New

Date Acquired

Tax Date

Previous Title No.

State

Cost of Vehicle

Less Trade

Used

Title Fee

Lic Pen Credit

Handling Fee

Rebate

Tax Value

Mortgage Fee

Tax

Tow Fee

DUPLICATE TITLE AFFIDAVIT (Must be signed by owner and notarized.)

The certificate of title issued to me was

License Fee

*Tax Penalty

Miscellaneous Fee

. lost

mutilated

never received

Lic Transfer Fee

*Interest

Total Fees

I make application for a duplicate copy of said certificate and agree to hold the

License Credit

Vendor's Comp

Total Taxes

Commissioner harmless if the previous title is obtained by another person.

I give the Commissioner permission to mail the title to the address on this

License Penalty

Tax Credit

Grand Total

application.

BE SURE TO SIGN AND DATE

I do swear or affirm that the information contained in this document is true and

Owner(s)'s Signature(s) for Duplicate Title

correct to the best of my knowledge.

I have and will maintain, during this registration period, vehicle liability insurance

Witness

Witness

(security) required by LRS Title 32:861-865. Failure to maintain as agreed will

Sworn and subscribed before me this ________ day of ____________, _______

be a violation of law which may result in criminal prosecution and/or suspension

of registration privileges.

Notary Public Signature, Printed Name

ID Number

If the vehicle being registered is defined as a commercial motor vehicle by the

AFFIDAVIT OF NON-POSSESSION OF TITLE BY LIENHOLDER.

Federal Motor Carrier Safety Regulations and/or Federal Hazardous Material

Regulations, by signature below registrant declares knowledge of those federal

Must be signed by lienholder and notarized.

regulations.

I hereby swear or affirm that title of above described vehicle showing lien in our

favor was

never received

received and surrendered to the owner.

Applicant's Signature

Date

Co-Applicant's Signature

Date

Lienholder's Signature

PROOF OF LIABILITY INSURANCE MUST BE FURNISHED AS

PROVIDED FOR BY LAW BEFORE THIS FILE CAN BE PROCESSED.

Witness

Witness

TO AVOID PENALTY AND INTEREST:

Sworn and subscribed before me this ________ day of ____________, _______

File must be submitted within 40 days from the date of purchase. For

manufactured houses (mobile homes), file must be submitted by the 20th of the

month following the month of delivery.

Notary Public Signature, Printed Name

ID Number

*Tax Penalty: 5% of sales tax due for 30 days or fraction thereof (not to

RECEIVED/REJECTION DATE(S)

.

exceed 25%).

*Interest: 1.25% of sales tax due for 30 days or fraction thereof

.

(no maximum).