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On Reverse FEE: $22.50 VEHICLE INFORMATION Title Number Vehicle Identification Number Last Name (or Full Business Name) First Name Co-Owner Last Name Middle Name CHECK BLOCK IF ADDRESS IS TO BE CHANGED Date of Birth Middle Name First Name PA DL/Photo ID# or Bus. ID# PA DL/Photo ID# Date of Birth Street Address NOTE: Complete only if different from address listed on original title. City Zip Code State REASON FOR DUPLICATE TITLE APPROPRIATE BLOCK MUST BE CHECKED Lost/ Destroyed.

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