Application for Texas Title and/or Re epic Tee che one Cl Title & Registration (I Title Only Ll Registration Purposes Only LI Nontitle Registration rape serra ek istration TAX OFFICE USE ONLY County Doe [C1 Vehicle Description Add/Remove Lien _C1 Other: sev Elaporacal value Vehicle Wdantieaton Nomber 2 Year ware [a soaysivie — |5. Model Is Major Color ]7- Minor Color [Texas icense Pate No. 3. Odometer Reading (vo eis) [10. Tiss the Actual Mileage unless the mleagels: |i, Empty Weight ]12.Carving Capacity Gani] [EiNotActual_C Exceeds Mechanical Limits Cl Exema| is. Appicant Type Ta, Apolcant Photo Number or FEN/EIN Cindividual Business ClGovernment Trust Non-Profit 5.10 Tyee CI USS. Driver Lcense/ID Card (esued by: ) Cl narow TUS. Dept. of state 1D 1D Passport (issued by: ) CLUs.miitayyio C1 US. Dept. of Homeland Security ID DUS. citizenship & immigration Services/001 1D other military status of Forces Photo 1D 6: Appicae Fst Name (or Entity Name) Mideie Ware st Nane Saf Tany) Fi. Aaaitonal Applicant Fst Name UF appiable) TMiddie Ware Tatham ‘Self any) a: Applcane Maing Adress or Sate ie 9, Applicant County of Residence 20, Previous Owner Name (or Enty Name) Gy ‘Slate [BA Dealer GON Fappeabie) 2. Unie Wo. (Fapplesbe) 25: Renewal Redplant Fst Name or Entity Name) (Fafevent) Middle Name Tastee Su any 2a, Renewal Notice Mailing Address ff afer) oy Siaie 2b ei 25. Applicat Phone Number [optional 25. Eval (optional) [¥. Registration Renewal eReminder [28 Communication impediment Yes (Provide mailin zs) __|T Yes fatach Form VTR-216) 9. Vehicle Lncaton Aare (aera) oy Sale Zp (50: watiste (aaaiuonat Liens JS, HecironeTWe Request ]s2, Certiea/eTile lesholaer10 Number (Fay) Sa retuespaen Fes (arach Form vie-267) | C1¥es(cannot check #30} [24 Fest eaholdar Name (Fany) — — Maling Adaress cy sate i fs, check ony appleatie TMOTOR VERICLE TAX STATEMENT 1D thold Mator Vehicle Retaller (Renal) Permit No. and wil ssf the minimum ta lity (V.AS, Tax Code §152.046), (D Lam a dealer o lessor and qualify to take the Fa Market Value Deduction VATS, Tax Code, §152.002c). GDN or Lessor Number 6. Tradein(ifany) Year ‘Make ‘Vehicle identestion Number 7. Adaiional ade mis) 1 Yes (complete) Dyes 58, Check only applicable: ‘SALES AND USE TAX COMPUTATION 1D (a) Sales Price (S rebate has been deducted) § 1 $90 New Resident Tax (Previous State) {b) Less Trade-in Amount, described in 8ox 36 above sc ) $5Even Trade Tax {e) For Dealers/Lessrs/Rental ONLY —Fir Market Value 1D $10 Tax attach comptroller Form 14317 Deduction described in Box 36 above st 1 S6SRebuit Sahage Fee {) Taxable mount (tem a minus tem Bor tem c) 8 1D 25% Emissions Fee (iesl Vehicles 1996 and Older > 14,000 bs {e} 625% Taxon Taxable Amount (Multiply Item d by 0625) $ 1D 19 Emissions Fee (Diesel Vehicles 2997 and Newer> 16000 Ibs) (0 Late Tax Payment Penalty © 5% or O 10% 5 [D_Exemption elsimed under the Motor Vehicle Sales and Use Tx Law Berauie (a) ToxPaid to (STATE) . {h) AMOUNT OF TAX AND PENALTY DUE 1D $2 or $33 Application Fe for Texas Title {teem pls em f minus tem g) (Contact your count ak asessorclletar forthe corect fee.) CCERTIACATION ~ State law makes falsiving information a third degree folony {hereby certify al statements inthis document are true and correct tothe best of my knowledge and belie an | zm eligible for ttl and/or registration as applicable). (check only if applicable | certify lam applying for 2 carected title and the ariginl Texas Cerificate of Tit i lator destroyed Signatures) of Sellers), Donors, or Traders) Printed Namels (Same a5 Signaturets) Date Signature of Aoplican/Owner Printed Name (Same as Signature) Date Signature) of Adaivonal Appeal Owner) Printed Namete (Same as Signatures) Date