MISSISSIPPI MOTOR TITLE APPLICATION
FOR OFICE USE
DATE
RETURN
RCVD.
RCVD. _________ CASH $_________ DATE__________ DATE _________
CCK$________________ CCK#________________________________
MO$________________ MO#________________________________
MISSISSIPPI MOTOR TITLE APPLICATION
Department of Wildlife, Fisheries, and Parks Boat Registration
1505 Eastover Drive Jackson, MS 39211-6374
601-432-2055
BOAT REGISTRATION # (If related)
DATE OF ISSUE
TITLE # PROCESSED BY:
CHECK THE APPLICABLE BOXES
1. New MS Motor Title
$12.70
4. Corrected Title Only
$12.70
2. Transfer MS Title 3. Duplicate Title
$12.70 $12.70
TOTAL AMOUNT REMITTED
$
If requesting a duplicate please furnish information concerning the original certificate and the circumstances of its loss, theft, mutilation or destruction.
MAKE CHECK OR MONEY ORDER PAYABLE TO MISSISSIPPI DEPT. OF WILDLIFE, FISHERIES, AND PARKS
LAST AP P LICAN T 'S NAME (PRINT)
FIRST
MIDDLE
DATE OF BIRTH SOCIAL SECURITY NUMBER
MAILING ADDRESS
STREET OR POST OFFICE BOX NUMBER
HOME TELEPHONE NUMBER
CITY
STATE
ZIP
COUNTY
U.S. CITIZEN?
WORK TELEPHONE NUMBER
YES
NO
E-Mail address
LAST A CO-OWNER (IF APPLICABLE)
DESCRIPTION OF OUTBOARD MOTOR MODEL YEAR
FIRST MANUFACTURER SERIAL #
MIDDLE
DATE OF BIRTH SOCIAL SECURITY NUMBER Horsepower VALUE OF MOTOR
FIRST LIEN
MOTOR
ADDRESS
MOTOR IS SUBJECT TO THE FOLLOWING LIENS
CITY, STATE, ZIP
TELEPHONE
NAME AND ADDRESS OF PERSON FROM WHOM MOTOR WAS PURCHASED
DATE OF LIEN
$ AMOUNT OF LIEN -
I CERTIFY THAT I OWN THE ABOVE MOTOR AND UNDERSTAND AND AGREE THAT AN EXAMINATION MAY BE MADE OF THE MOTOR BY THE STATE OF MISSISSIPPI, DEPARTMENT OF WILDLIFE, FISHERIES AND PARKS. STATE OF ______________________________________ Appeared before me _______________________________________________, who first being duly SWORN says that of his or her own personal knowledge all the information given and STATEMENTS made on the application are true and correct and that the motor described is subject to no liens or encumbrances except as noted on the application. THIS THE ______________________________________________ DAY OF ___________________________________________________, 20___________
APPLICANT'S SIGNATURE
DRIVERS LICENSE NO.
NOTARY'S SIGNATURE
MY COMMISSION EXPIRES
CO-OWNER'S SIGNATURE
DRIVERS LICENSE NO.
DEALER'S SIGNATURE
DEALER PERMIT NUMBER
Mississippi Code Section 97-7-10 states (in Part).... "Whoever makes or uses any false, fictitious, or fraudulent statement or entry, shall, upon conviction be punished by a fine of not more than $10,000.00 or by imprisonment for not more than 5 years, or by both such fine and imprisonment."
Return White Copy - Keep Yellow Copy
REV. 12/09
FOR OFFICE USE
DATE
RETURN
RCVD.
RCVD. _________ CASH $_________ DATE__________ DATE _________
CCK$________________ CCK#________________________________
MO$________________ MO#________________________________
MISSISSIPPI BOAT TITLE APPLICATION
Department of Wildlife, Fisheries, and Parks Boat Registration
1505 Eastover Drive Jackson, MS 39211-6374
601-432-2055
BOAT REGISTRATION #
MI ?
DATE OF ISSUE
TITLE # PROCESSED BY:
1. New MS Boat Title 2. Transfer MS Title 3. Duplicate Title
CHECK THE APPLICABLE BOXES
$12.70
4. Corrected Title Only
$12.70
$12.70
TOTAL AMOUNT REMITTED
$
$12.70
If requesting a duplicate please furnish information concerning the original certificate and the circumstances of its loss, theft, mutilation or destruction.
MAKE CHECK OR MONEY ORDER PAYABLE TO MISSISSIPPI DEPT. OF WILDLIFE, FISHERIES, AND PARKS
AP P LICAN T 'S NAME (PRINT)
MAILING ADDRESS CITY
LAST
FIRST
STREET OR POST OFFICE BOX NUMBER
STATE
ZIP
E-Mail address
MIDDLE COUNTY
DATE OF BIRTH SOCIAL SECURITY NUMBER
HOME TELEPHONE NUMBER
U.S. CITIZEN?
WORK TELEPHONE NUMBER
YES
NO
A CO-OWNER LAST (IF APPLICABLE)
FIRST
MIDDLE
DATE OF BIRTH SOCIAL SECURITY NUMBER
FIRST LIEN
HULL IDENTIFICATION NUMBER
DESCRIPTION OF BOAT MODEL YEAR
MAKE
VALUE OF BOAT
LENGTH
FT
IN
BOAT
ADDRESS
BOAT IS SUBJECT TO THE FOLLOWING LIENS
CITY, STATE, ZIP
TELEPHONE
NAME AND ADDRESS OF PERSON FROM WHOM BOAT WAS PURCHASED
DATE OF LIEN
$ AMOUNT OF LIEN
I CERTIFY THAT I OWN THE ABOVE BOAT AND UNDERSTAND AND AGREE THAT AN EXAMINATION MAY BE MADE OF THE BOAT BY THE STATE OF MISSISSIPPI, DEPARTMENT OF WILDLIFE, FISHERIES AND PARKS. STATE OF ______________________________________ Appeared before me _______________________________________________, who first being duly SWORN says that of his or her own personal knowledge all the information given and STATEMENTS made on the application are true and correct and that the watercraft described is subject to no liens or encumbrances except as noted on the application. THIS THE ______________________________________________ DAY OF ___________________________________________________, 20______
APPLICANT'S SIGNATURE
DRIVERS LICENSE NO.
NOTARY'S SIGNATURE
MY COMMISSION EXPIRES
CO-OWNER'S SIGNATURE
DRIVERS LICENSE NO.
DEALER'S SIGNATURE
DEALER PERMIT NUMBER
Mississippi Code Section 97-7-10 states (in Part).... "Whoever makes or uses any false, fictitious, or fraudulent statement or entry, shall, upon conviction be punished by a fine of not more than $10,000.00 or by imprisonment for not more than 5 years, or by both such fine and imprisonment."
Return White Copy - Keep Yellow Copy
REV. 12/09
................
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