Free 12907.FH11 - Indiana

APPLICATION FOR SPECIAL IDENTIFICATION NUMBER FOR MOTOR VEHICLE, HOUSE CAR AND OTHER SELF-ASSEMBLED MOTOR VEHICLES.
State Form 12907 (R3 / 6-00) / Form T-1A Approved by State Board of Accounts, 2000

STATE OF INDIANA BUREAU OF MOTOR VEHICLES INDIANAPOLIS, IN 46204
Branch number Invoice number MVIN number IND Fee

The undersigned hereby makes application for permission to affix a special identification number on the vehicle described herein in an easily accessible place on the vehicle. This application will not be considered unless every blank is properly filled, and the same signed under penalty of perjury and accompanied by the statutory fee.
PLEASE PRINT OR TYPE
Name of applicant (first, middle, last)

Date (month, day, year)

Address (number and street, city, state, ZIP code)

County

Type of vehicle (i.e: semi-trailer, house car, privately assembled motor vehicle)

Style of body

Make

Model

Year

License number

Date of purchase

Title number

Identification number

From whom purchased (first, middle, last)

Address (number and street, city, state, ZIP code)

Give a description of defacement or mutilation or other reasons why no serial or identification number appears on the vehicle described above. (i.e.: numbers chiseled off, privately assembled, plate removed, idented numbers filed in)

I, do swear or affirm that the information I have entered on this form is correct. I understand that making a false statement on this form may constitute the crime of perjury.
Signature of applicant (must be signed in ink) Printed name of applicant Date