State Form 44049 – Fill Out and Use This PDF

State Form 44049 (R4 / 3-02)

Approved by State Board of Accounts 2002

TO BE COMPLETED BY A POLICE OFFICER, BMV OFFICIAL OR BMV CERTIFIED DEALER SIGNEE

I/WE THE UNDERSIGNED SWEAR OR AFFIRM THAT THE INFORMA-

FOR

OUT OF

STATE TITLES. I HEREBY CERTIFY THAT I PERSONALLY EXAM-

TION ENTERED ON THIS FORM IS CORRECT. I/WE UNDERSTAND

INED THE FOLLOWING VEHICLE AND FIND THE IDENTIFICATION NUMBER TO BE AS FOLLOWS.

THAT MAKING A FALSE STATEMENT ON THIS FORM MAY CONSTI-

VEHICLE IDENTIFICATION NUMBER

TUTE THE CRIME OF PERJURY. FUTHERMORE, I/WE AGREE TO

INDEMNIFY AND HOLD HARMLESS THE INDIANA BMV FROM ANY

11

13

17

LIABILITY ARISING FROM THIS TRANSACTION.

YR.

MAKE

MODEL

TYPE

DATE

X __________________________________________________________

X __________________________________________________________

INSPECTOR'S PRINTED NAME & TITLE

CITY

DATE: ______________________________________________________

The law requires that you apply for Certificate of Title within thirty-one days from the date of purchase of a

INSPECTOR'S SIGNATURE

BADGE, BRANCH OR

motor vehicle. There is a delinquent fee for failure to do so. Attach Certificate of Title assigned by seller. On en-

DEALER PLATE NO.

dorsed Titles, liens must be released. Supporting documents surrendered with this application cannot be returned to the appli-

cant. *In accordance with Federal Code 383.

TITLE NUMBER

BRANCH NO.

INVOICE NO.

BMV USE ONLY

1.

*SOC. SEC./FEDERAL I.D.NO.

APPLICANT'S NAME

BMV USE ONLY

2.

STREET ADDRESS

CITY

STATE

ZIP CODE

3.

VEHICLE I.D. NUMBER

VEH.YEAR

VEH. MAKE

VEH. MODEL NO.

VEH TYPE

ODOMETER

4.

FORMER TITLE NUMBER

PURCHASE DATE

LIEN

SPEED

PICK UP

MAIL

DEALER NO.

BMV USE ONLY

5.

FIRST LIEN'S NAME OR SPECIAL MAILING ADDRESS

STREET ADDRESS

6.

CITY

STATE

ZIP CODE

BMV USE ONLY

7.

SECOND LIEN'S NAME

STREET ADDRESS

8.

CITY

STATE

ZIP CODE

LICENSE NUMBER

LICENSE

FORMS

BMV USE ONLY

9.

YEAR

USED

GROSS RETAIL & USE TAX AFFIDAVIT - I/WE HEREBY CERTIFY THAT SALES OR USE TAX ON THIS VEHICLE WAS PAID AS INDICATED BELOW.

SELLING PRICE

LESS TRADE-IN *

AMOUNT SUBJECT TO TAX

AMOUNT OF TAX

DEALER

BRANCH

EXEMPT

IF EXEMPT

10.

$

$

$

$

PLACE PARA.#