82523
STATE OF MICHIGAN
APPLICATION FOR MICHIGAN TITLE & REGISTRATION STATEMENT OF VEHICLE SALE
______________
Invoice/Stock No.
DEPARTMENT OF STATE
Purchase Date_________________________ Delivery Date__________________________
Dealer
______________
Invoice/Stock No.
Expires On Month Day
Months Year
s NEW PLATE s RENEWAL s TRANSFER
Code County License Fee
Address
Year
Make
Body Style
City County State Zip Code
Vehicle No.
Fee Category/Weight
Driver License No./PIDs of All Owners or Lessees 1) 2) 3) County of Residence
Title
MICHIGAN
Dealer License Sales Tax License Phone Number
Title Late Fee
Vehicle Sold New
Trade-In Year
s
Used
s
Demo
s
Trade-In
Yes
s
No
s
Complete Names and Addresses of All Owners or Lessors
Tax
Make
Vehicle No.
Reg. Transfer Fee
Total - Transfer to #4 TEMPORARY VEHICLE REGISTRATION USED TO TRANSFER PLATES Expires 15 days after delivery date Plate transferred from: Year Make Complete Names and Addresses of All Lessees
Full Rights to Survivor Yes
Vehicle No.
Plate No.
Temp. Expiration Date Insurance Company Policy No. or Binder No.
s
No
s
VEHICLE USE AND HISTORY DISCLOSURE:
s POLICE VEHICLE s GOVERNMENT VEHICLE s TAXI
s VEHICLE HAS BEEN FLOOD-DAMAGED s SALVAGE TITLE HAS PREVIOUSLY BEEN ISSUED s __________________________________________
ODOMETER MILEAGE
First Secured Interest _____________________________________________________
Filing Date
Address _______________________________________________________________________ City-State Zip Second Secured Interest______________________________________________________ Filing Date
The following section must be completed when odometer disclosure is required. The odometer mileage reading must match the mileage reading disclosed to the purchaser on the title and/or mileage statement.
NO TENTHS
Address _______________________________________________________________________ City-State Zip
s actual mileage s not actual mileage s exceeds mechanical limits of odometer Factory Installed Accessories s Factory List Affixed To Vehicle
01. PURCHASE PRICE OF VEHICLE (Including Freight & Accessories) 02. OTHER TAXABLE CHARGES (Documentary Fee, Service Fee, Temp. Reg. Fee, Etc.) 03. TOTAL TAXABLE PRICE 04. (Above total) SALES TAX - LICENSE - TITLE
Dealer Installed Accessories When Optional to Purchaser
05. NON-TAXABLE CHARGES (Labor, Service Contract, Etc.) 06. TOTAL DELIVERED PRICE 07. CASH ON DEPOSIT 08. CASH DUE ON DELIVERY 09. TRADE-IN
$ $
REMARKS:
10. LESS LIEN 11. TOTAL DOWN PAYMENT 12. UNPAID BALANCE TO BE FINANCED 13. INSURANCE CHARGE*
14. TOTAL AMOUNT OF FINANCE CONTRACT
CONTRACTUAL DISCLOSURE STATEMENT FOR USED VEHICLES ONLY "The information you see on the window form for this vehicle is part of this contract. Information on the window form overrides any contrary provisions in the contract of sale." "I CERTIFY I SOLD THIS VEHICLE TO THE PURCHASER NAMED IN THIS FORM. I WARRANT THE TITLE TO THE VEHICLE AND CERTIFY THAT THE VEHICLE IS SUBJECT ONLY TO THE SECURITY INTERESTS NAMED ABOVE." *TYPE OF INSURANCE WARNING: This insurance is not PL/PD No Fault Insurance required by Michigan Law.
s s
CREDIT LIFE GAP INSURANCE
s s
HEALTH & ACCIDENT __________________________________
Temporary Temporary Registration No.______________________________________ Fee Charged Yes Dealer's Signature Title
s
No
s
Salesperson ____________________________________________________________________
PURCHASER WARNING: DO NOT SIGN BLANK FORM
I am purchasing or leasing this vehicle and am applying for a Michigan certificate of title and registration or, if the lessee, applying for a registration. I certify my driver license is not suspended, revoked, or denied as a repeat offender and I am eligible to purchase or register this vehicle. I further certify that if a tax exemption is shown above it is valid. X ___________ ______________________________________________________________
Date Date Date
X ___________ _______________________________________________________________
Date Date Date
X ___________ ______________________________________________________________ X ___________ ______________________________________________________________
Purchaser's/Lessor's Signature(s)
X ___________ _______________________________________________________________ X ___________ _______________________________________________________________
Lessee's Signature(s)
PURCHASERS NOTE: IF VEHICLE TITLE IS NOT RECEIVED WITHIN 30 DAYS, CONTACT THE BUREAU OF REGULATORY SERVICES AT 1-800-292-4204
Authority granted by P.A. 300 of 1949, as amended.
THIS FORM MUST BE TYPED ONLY
RD-108 12/02