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 ELECTRONIC FUND
TRANSFER CODE
Date Prepared Type of Plate DEALER CODE
VEHICLE APPLICATION
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?
If lessee, domicile, or renter is indicated, renewal notice should be mailed to (check one): Domicile Code
Lessee Mail To Domicile Renter
. 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

Date Acquired Tax Date Previous Title No. State Cost of Vehicle Less Trade
New
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.)
License Fee *Tax Penalty Miscellaneous Fee The certificate of title issued to me was
. 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.

License Penalty Tax Credit Grand Total I give the Commissioner permission to mail the title to the address on this
application.
BE SURE TO SIGN AND DATE
Owner(s)'s Signature(s) for Duplicate Title
I 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 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

Federal Motor Carrier Safety Regulations and/or Federal Hazardous Material AFFIDAVIT OF NON-POSSESSION OF TITLE BY LIENHOLDER.
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
Applicant's Signature Date favor was never received received and surrendered to the owner.

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).
DPSMV 1799 (R01/18)
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.

A. CONVERSION
Old License Plate Number _____________________ New License Plate Number _____________________
Use _____________________ Use _____________________
Weight _____________________ Weight _____________________
B. TRANSFER OF PLATE
License plate ___________________ has been removed from a _______________________________________________________
YEAR MAKE VIN

and transferred to the vehicle described on the first page of this form. License plate returned is ______________________________

C. LOST, STOLEN, OR REPLACEMENT PLATE STICKER License Plate Number ________________

D. TITLE CORRECTION
Error: _____________________________________________________________________________________________________

__________________________________________________________________________________________________________

Correct To: ________________________________________________________________________________________________

__________________________________________________________________________________________________________
E. FARM 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:
________________________________________________________________________________________________________________
RFD Box City Parish Zip

________________________________________________________________________________________________________________
Owner's Signature
F. OUT OF STATE DECLARATION
I, declare that the
(Printed name of owner) MAKE MODEL VIN
was domiciled in Louisiana on .

G. DISCLOSURE OF SALVAGE / RECONSTRUCTED / WATER DAMAGED / HAIL-DAMAGED

I, swear under penalties of perjury that:
(Printed name of owner)
the title covering the vehicle, , in accordance with
MAKE MODEL VIN
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
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.
Hail-Damaged

Signed by under penalties of perjury this day of

(Signature of vehicle owner)
, 20

False statements are punishable by fine, imprisonment or both under R.S. 32:730.