Louisiana Department of Public Safety and Corrections
Office of Motor Vehicles
ELECTRONIC FUND
P.O. Box 64886, Baton Rouge, LA 70896-4886
TRANSFER CODE

TO AVOID REJECTION:
Complete all required information
Date PreparedType of Plate

VIN

Make

Body

Color

DEALER CODEVEHICLE APPLICATIONYear

Mileage

License No.

Exp. Date

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)

ParishCityLessee

Mail ToDomicile

I affirm that the information provided is in compliancewith R.S. 47:303.

State/Zip

If lessee, domicile, or renter is indicated, renewal notice should be mailed to (check one):.
Owner
Lessee, renter, or domicile address

RenterName

Driver's License or EIN of Lessee or Renter

StreetTrade VIN

ParishCity

Trade License No.

State/Zip

VEHICLE IS SUBJECT TO SECURITY AGREEMENT AS FOLLOWS:ELECTRONIC LIEN
TRANSFER CODE

New
Used

Date Acquired

First Lienholder's Name

Second Lienholder's Name

StreetStreet

City/State/Zip

City/State/Zip

Tax Date

Previous Title No.

StateTitle Fee

Lic Pen Credit

Handling Fee

Mortgage Fee

TaxTow Fee

License Fee*Tax Penalty

Miscellaneous Fee

Lic Transfer Fee*Interest

Total Fees

License Credit

Vendor's Comp

Total Taxes

License Penalty

Tax Credit

Grand Total

Cost of Vehicle

Less Trade

RebateTax Value

DUPLICATE TITLE AFFIDAVIT (Must be signed by owner and notarized.)
The certificate of title issued to me was. lostmutilated

I give the Commissioner permission to mail the title to the address on thisapplication.

BE SURE TO SIGN AND DATE

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 suspensionof registration privileges.
If the vehicle being registered is defined as a commercial motor vehicle by theFederal Motor Carrier Safety Regulations and/or Federal Hazardous Material
Regulations, by signature below registrant declares knowledge of those federal
regulations.

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

Witness

WitnessSworn and subscribed before me this ________ day of ____________, _______
Notary Public Signature, Printed Name

ID Number

AFFIDAVIT OF NON-POSSESSION OF TITLE BY LIENHOLDER.
Must be signed by lienholder and notarized.

Applicant's Signature

Date

I hereby swear or affirm that title of above described vehicle showing lien in ourreceived and surrendered to the owner.
favor wasnever received

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.

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 themonth following the month of delivery.
For additional information on penalty and interest, refer to Section 4, Policy
55.00,
Penalty and Interest on Expresslane.org.
.
.

never received

I make application for a duplicate copy of said certificate and agree to hold theCommissioner harmless if the previous title is obtained by another person.

I do swear or affirm that the information contained in this document is true andcorrect to the best of my knowledge.

DPSMV 1799 (R05/24)

Domicile CodeWitnessWitness

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

Notary Public Signature, Printed Name

RECEIVED/REJECTION DATE(S)ID Number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.

B.

CONVERSION

Old License Plate Number _____________________

New License Plate Number _____________________

Use _____________________

Use _____________________

Weight _____________________

Weight _____________________

TRANSFER OF PLATE
License plate ___________________ has been removed from a _______________________________________________________YEAR

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

LOST, STOLEN, OR REPLACEMENTD.

TITLE CORRECTION

PLATE

STICKER

License Plate Number ________________

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 usedprimarily, but not exclusively, in hauling farm produce raised on my farm, from such farm to market and return therefrom; haulingmerchandise to my farm and that this vehicle will not be used to haul another person's farm produce or other products for a fee orcompensation. Said farm is located at:________________________________________________________________________________________________________________RFDBoxCityParishZip________________________________________________________________________________________________________________
Owner's SignatureF.

OUT OF STATE DECLARATION
I,declare that the(Printed name of owner)

MAKE

G.

MODEL

VIN.

was domiciled in Louisiana on

DISCLOSURE OF SALVAGE / RECONSTRUCTED / WATER DAMAGED / HAIL-DAMAGEDI,

swear under penalties of perjury that:(Printed name of owner)

the title covering the vehicle,

MAKE

Louisiana R.S. 32:706.1, has been branded:

MODEL, in accordance withVIN

Salvaged VehicleReconstructed 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

ComputerElectrical 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(Signature of vehicle owner)

under penalties of perjury this day of, 20
False statements are punishable by fine, imprisonment or both under R.S. 32:730.