Date Prepared(Required) MM slash DD slash YYYY Type of Plate(Required)StandardSpecialtyVIN(Required)Make of Vehicle(Required)License Plate Number(Required)Expiration Date(Required) MM slash DD slash YYYY VIN(Required)Body(Required)For example, Sedan, Coupe, Pickup, Van, SUVModel/Weight(Required)Model/Weight(Required)Year(Required)Please enter a number from 1900 to 2100.Mileage(Required)Please enter a number greater than or equal to 5.Vehicle Owner's Name(Required) First Last Driver's License or EIN(Required)Name of Joint Owner First Last Driver's License or EIN(Required)Owner's Principal Residence Address (or Business Location if Vehicle is Used for Commercial Purposes)(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code I affirm that the information provided is in compliance with R.S. 47:303. Choose One Mail to Above Address Lessee Mail To Domicile Renter If lessee, domicile, or renter is indicated, renewal notice should be mailed to (check one): Owner Lessee, renter, or domicile address Driver's License or EIN of Lessee or Renter(Required)Trade License No.(Required)Trade VIN(Required)Additional Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code I affirm that the information provided is in compliance with R.S. 47:303. VEHICLE IS SUBJECT TO SECURITY AGREEMENT AS FOLLOWS:Any inaccurate information will cause delays in processing.First Lienholder's Name First Last First Lienholder's Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code I affirm that the information provided is in compliance with R.S. 47:303. Second Lienholder's Name First Last Second Lienholder's Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code I affirm that the information provided is in compliance with R.S. 47:303. New or Used?(Required) New Used Date Acquired(Required) MM slash DD slash YYYY Previous Title No.StateCost of Vehicle(Required)Is this a Duplicate Title?(Required) Yes No DUPLICATE TITLE AFFIDAVIT(Must be signed by owner and notarized.)The certificate of title issued to me was(Required) lost mutilated never received Consent I give the Commissioner permission to mail the title to the address on this application.I make application for a duplicate copy of said certificate and agree to hold the Commissioner harmless if the previous title is obtained by another person. You will need to have this notarized in person.PROOF OF LIABILITY INSURANCE MUST BE FURNISHED AS PROVIDED FOR BY LAW BEFORE THIS FILE CAN BE PROCESSED.TO AVOID PENALTY AND INTEREST: 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. For additional information on penalty and interest, refer to Section 4, Policy 55.00, Penalty and Interest on Expresslane.orgBE SURE TO SIGNI do swear or affirm that the information contained in this document is true and correct to the best of my knowledge. I have and will maintain, during this registration period, vehicle liability insurance (security) required by LRS Title 32:861-865. Failure to maintain as agreed will be a violation of law which may result in criminal prosecution and/or suspension of registration privileges. If the vehicle being registered is defined as a commercial motor vehicle by the Federal Motor Carrier Safety Regulations and/or Federal Hazardous Material Regulations, by signature below registrant declares knowledge of those federal regulations. NOTICE:If a title, license plate, or validation sticker is not received within thirty (30) days after submitting application and fees for such, contact your nearest Office of Motor Vehicles. Departmental policy provides for the issuance of a free replacement within sixty (60) days from the date of issuance. Failure to notify this office timely could result in additional fees being charged. False statements are punishable by fine, imprisonment or both under R.S. 32:730. Title Reason CONVERSION TRANSFER OF PLATE LOST, STOLEN, OR REPLACEMENT TITLE CORRECTION FARM USE STATEMENT OUT OF STATE DECLARATION DISCLOSURE OF SALVAGE / RECONSTRUCTED / WATER DAMAGED / HAIL-DAMAGED Section A: CONVERSIONOld License Plate NumberWeightUseNew License Plate NumberUseWeightSection B. TRANSFER OF PLATELicense platehas been removed from aYEARMakeVINand transferred to the vehicle described on the first page of this form. License plate returned isSection C. LOST, STOLEN, OR REPLACEMENTWhat was lost, stolen, or needs replacement? PLATE STICKER License plateSection D. TITLE CORRECTIONError:Correct To:Section E. FARM USE STATEMENTFarm Use Statement I do declare that I am a bona fide farmer and am in the business of farming; that the vehicle described on the first page of this form is used primarily, but not exclusively, in hauling farm produce raised on my farm, from such farm to market and return therefrom; hauling merchandise to my farm and that this vehicle will not be used to haul another person's farm produce or other products for a fee or compensation. Said farm is located at:RFDBoxCityParishZIPSection F. OUT OF STATE DECLARATIONName First Last ModelVINwas domiciled in Louisiana on MM slash DD slash YYYY Section G. DISCLOSURE OF SALVAGE / RECONSTRUCTED / WATER DAMAGED / HAIL-DAMAGEDName First Last swear under penalties of perjury that: the title covering the vehicle,MakeModelVINin accordance with Louisiana R.S. 32:706.1, has been branded: Salvaged Vehicle Reconstructed Vehicle In accordance with Louisiana R.S. 32:789, the undersigned confirm that the above referenced vehicle has sustained water damage to the following extent:In accordance with Louisiana R.S. 32:781, the undersigned confirm that the above referenced vehicle has sustained water damage to the following components: Power Train Computer Electrical System Hail Damage In accordance with Louisiana R.S. 32:702(13), the undersigned confirm that the above referenced vehicle has sustained only cosmetic damage caused by hail, equivalent to seventy-five percent or more of its market value as a result of costs or repairs to items such as windshield, windows, and rear glass; exterior paint and paint materials; and body damage such as dents.
