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CONTROL FEDERAL AND STATE LAWS REQUIRE THAT YOU STATE THE MILEAGE IN CONNECTION WITH THE TRANSFER OF OWNERSHIP.MINNESOTA
NUMBER LAW REQUIRES THAT YOU MAKE A DISCLOSURE ABOUT DAMAGE TO THE VEHICLE. A FALSE OR FRAUDULENT STATEMENT OF PURCHASE
BY ANY PERSON IS A GROSS MISDEMEANOR OR FELONY.
SALES TAX DECLARATION AND FEES
$ REGISTRATION TAX $
FULL PURCHASE PRICE
PLATE FEE
LESS TRADE-IN ALLOWANCE
ARREARS TAX
NET PURCHASE PRICE
%OF NET PURCHASE PRICE
LESS TAX PAID TO ANOTHER STATE
NET SALES TAX DUE $ PSV FEE
TRANSFER TAX
TRADE-IN WAS A: TITLE/TRANSFER FEE
MODEL MAKE PLATE OR VEHICLE IDENTIFICATION NUMBER SALES TAX
YEAR
Minnesota Dealer's License Number. LATE TRANSFER PENALTY
I DECLARE Minnesota Sales Tax Account Number: SUBTOTAL $
THIS TAX
EXEMPTION Internal Revenue Code Number(IRC): STATE/DEPUTY FILING FEE
CODE: IRP Acct Number:
TOTAL DUE $
If Leased,Lessee MCDP Number:
REASSIGNMENT BY LICENSED DEALER ONLY I(WE)CERTIFY THAT THIS VEHICLE IS FREE FROM ALL SECURITY INTERESTS,
WARRANT TITLE,AND ASSIGN THE REGISTRATION TAX AND VEHICLE TO(BUYER):
ODOMETER DISCLOSURE STATEMENT. I(WE)CERTIFY THAT THE ODOMETER NOW 0 IS ACTUAL MILEAGE
READS (NO TENTHS)MILES AND TO THE BEST OF MY 0 EXCEEDS MECHANICAL LIMITS OF ODOMETER
KNOWLEDGE THE ODOMETER MILEAGE: 0 IS NOT ACTUAL MILEAGE—WARNING ODOMETER DISCREPANCY
DAMAGE DISCLOSURE STATEMENT. TO THE BEST OF MY KNOWLEDGE,THIS VEHICLE:
❑HAS 0 HAS NOT(CHECK ONE)SUSTAINED DAMAGE,EXCLUSIVE OF ANY COSTS TO REPAIR,REPLACE,OR REINSTALL AIR BAGS AND OTHER
COMPONENTS THAT WERE REPLACED DUE TO DEPLOYMENT OF AIR BAGS, IN EXCESS OF 70 PERCENT ACTUAL CASH VALUE.
SELLER'S PRINTED NAME(S) DATE OF SALE BUYER'S PRINTED NAME(S)
SELLER'S ADDRESS DEALER'S LICENSE# BUYER'S ADDRESS
X X
SELLER'S SIGNATURE(S) BUYER'S SIGNATURE(S)
ODOMETER DISCLOSURE STATEMENT. I(WE)CERTIFY THAT THE ODOMETER NOW 0 IS ACTUAL MILEAGE
READS (NO TENTHS)MILES AND TO THE BEST OF MY 0 EXCEEDS MECHANICAL LIMITS OF ODOMETER
KNOWLEDGE THE ODOMETER MILEAGE: 0 IS NOT ACTUAL MILEAGE—WARNING ODOMETER DISCREPANCY
DAMAGE DISCLOSURE STATEMENT. TO THE BEST OF MY KNOWLEDGE,THIS VEHICLE:
❑HAS 0 HAS NOT(CHECK ONE)SUSTAINED DAMAGE,EXCLUSIVE OF ANY COSTS TO REPAIR,REPLACE,OR REINSTALL AIR BAGS AND OTHER
COMPONENTS THAT WERE REPLACED DUE TO DEPLOYMENT OF AIR BAGS,IN EXCESS OF 70 PERCENT ACTUAL CASH VALUE.
SELLER'S PRINTED NAME(S) DATE OF SALE BUYER'S PRINTED NAME(S)
SELLER'S ADDRESS DEALER'S LICENSE# BUYER'S ADDRESS
X X
SELLER'S SIGNATURE(S) BUYER'S SIGNATURE(S)
IMPORTANT-PLEASE READ: ALL INFORMATION COLLECTED ON A MOTOR VEHICLE APPLICATION IS MINNESOTA DEPARTMENT OF PUBLIC SAFETY
REQUIRED BY LAW AND IS ISSUED TO IDENTIFY YOUR MOTOR VEHICLE.FAILURE TO PROVIDE REQUIRED DRIVER AND VEHICLE SERVICES DIVISION
INFORMATION MAY RESULT IN DENIAL OF THE REQUESTED ACTION.EXCEPT FOR CERTAIN USES 445 MINNESOTA STREET,ST.PAUL,MINNESOTA 55101
PERMITTED BY FEDERAL AND STATE LAWS,PERSONAL INFORMATION CONTAINED IN YOUR APPLICATION PHONE 651-297-2126 TTY 651-282-6555
MAY NOT BE DISCLOSED TO ANYONE WITHOUT YOUR EXPRESS CONSENT.YOU MAY EXPRESSLY CONSENT
TO THE DISCLOSURE OF YOUR INFORMATION BY WRITING TO THE FOLLOWING ADDRESS: mndriveinfo.orq
SELLER'S NOTICE OF SALE
FOR YOUR PROTECTION
Date of Sale Purchaser's Driver License Number
UPON THE SALE OF A VEHICLE TO A PRIVATE
PARTY, WE RECOMMEND THAT THE SELLER
AND BUYER TAKE THE COMPLETED TRANSFER Purchaser's Full Name Date of Birth
TO A DEPUTY REGISTRAR.
Street Address
City County State Zip Code
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