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Division of Motor Vehicles UTAH STATE TAX COMMISSION 210 North 1950 West Salt Lake City Utah 84134 Telephone 801 297-7780 or 1-800-DMV-UTAH Clear form Application For Utah Duplicate Title 6. O. Box Fleet Number VIN/HIN Year Model Make I/We certify that the original certificate of title for this vehicle has not been endorsed and delivered to a transferee or delivered to a lending institution and/or pledged as collateral. I/We hereby make application for a duplicate certificate of title in lieu of the certificate that was lost stolen mutilated or illegible and agree to indemnify the Utah State Tax Commission and all persons acting under its direction from any and all liability and shall defend at my/our expense all litigation which may arise as a result of the issuance of the duplicate certificate of title. 00 Fee Required Owner Information Address Information Primary Owner s Name Last First Middle Initial Street Address Secondary Owner s Name City Business Name FEIN Unit Number State ZIP Code P. Owner/Applicant s Signature Date Lien Holder Information Lien Release Section Lienholder of Record Name Signature of lien holder of record releasing interest Address Title Assignment and Release of Interest Section Odometer Disclosure Required Reflects the actual mileage for this vehicle Is not the actual mileage for this vehicle Warning - Odometer discrepancy Enter mileage no tenths Sales Purchase Price - Required Sale Price Date of Sale Print name of seller Current address of seller street city state and ZIP Code As owner s I/We hereby transfer all rights title and interest to this vehicle to the new owner named below. I/We certify to the best of my/our knowledge that the title is free and clear of encumbrances except the lien to the new lien holder if any. I/We certify that the odometer and sales information provided is correct. Federal and state law require 1 the owner provide the mileage upon transfer of ownership of a vehicle and 2 the owner must disclose any brand information recorded on the last Certificate of Title. New Owner s Section New Lien Holders Section Name A Tow Truck 34025 West old US Hwy 40 Duchesne UT 84021-1085 Signature of new owner s TC-123 Rev* 10/04. Owner/Applicant s Signature Date Lien Holder Information Lien Release Section Lienholder of Record Name Signature of lien holder of record releasing interest Address Title Assignment and Release of Interest Section Odometer Disclosure Required Reflects the actual mileage for this vehicle Is not the actual mileage for this vehicle Warning - Odometer discrepancy Enter mileage no tenths Sales Purchase Price - Required Sale Price Date of Sale Print name of seller Current address of seller street city state and ZIP Code As owner s I/We hereby transfer all rights title and interest to this vehicle to the new owner named below. I/We certify to the best of my/our knowledge that the title is free and clear of encumbrances except the lien to the new lien holder if any. I/We certify to the best of my/our knowledge that the title is free and clear of encumbrances except the lien to the new lien holder if any. I/We certify that the odometer and sales information provided is correct. Federal and state law require 1 the owner provide the mileage upon transfer of ownership of a vehicle and 2 the owner must disclose any brand information recorded on the last Certificate of Title..

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