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2. Bill Information
4. Tax Year*
5. Bill Number
7. Plate/Registration Number*
8. Vehicle Year*
9. Make & Model*
11. Name (As Shown on Bill)*
13. Address (as shown on bill)*
15. Mailing Address (if different)
17. Plate Cancellation or New Registration*
18. Transfer of Ownership Documentation:*

    Documentation Examples:

    -Purchase and Sales Agreement (Traded)
    -Bill of Sale
    -Insurance Settlement Letter (Total Loss)
    -Junk Yard Receipt
    -Lemon Law (Letter from Dealership)
    -New State Registration

20. Signature*

    Subscribed under the penalties of perjury

21. Date*
    Date
23. Phone Number:*
25. Email:*
Leave This Blank:


27. 1. Receive an email copy of this form.
28. Email address

    This field is not part of the form submission.

29. Submit

* indicates a required field