HomeMy WebLinkAbout1993 Chev. Squad (2) APPLICATION TO TITLE/REG A VEHICLE PLATENUMB"
YEAR FOR VALET TION Amy ORKE&ONLY '
FOR CENTRAL OFFICLLISE ONLY
STICKER NUMIIER YEAR it ',-^ 1
if
ir
i
TITLE TITLE REQ REQ TER PREVIOUS PLATE NUMMI YEAR MONTH YEAR
A . 6 REQ EXPIRATION
ONLY ONLY CHANGE DEC
"P ' 1 i/0 !a!�'199
�
DATE
PURCHASER(S) DATE OF PURCHASE CRACK TLRAL OAS
OWNER(S) �r NEW t f USED Ma oR PRovANE i t
MUST /�—/E!/— 7 6 �( TYPE DESK OTHER
WA rt a. ".r'1
S .�J'a3. .N_C.Ci,__ I
COMPLETE MODEL YEAR MAKE BODY/MODEL TYPE 07
.n// Al � NON-NEOOTIARLE REGISTRATION RECEIPT(CARD)AND CAE CARD
vII NOIR ► 93 /t1 �,,r1�s,.s '. 7,L,/ THIS COPY WHEN VALIDATED OR 111E C(SETVAfRRVAELD ON THE UPPER RIGHT
OFFICE,WILL SERVE AS ECVOORENNECR))IV
A DEPUTY Of
information VEHICLE IDENTIFICATION NUMBER V P �� t TAX REGISTRAR
PPEERIOOD R'DICATER THE REGISTRATION PLATES SHOWN ON
COLOR BSI ROOF THIS RE DESCRIBED.
HAVE BEEN
ASSIGNED TO THE OWNER FOR USE ONLY ON THE
/(.1'8.Z 6-37 YO//to 3 79' GGOE: D (yr
PUCIIASEE(SI ►LAST,FIRST,AND MIDDLE NAME DRIERS LICE�E NO DATE OF BIRTH
OWNER(S) ,/� l
information Lr.i +R # g& �e L." A 1.S . I I
ADDITIONAL ( OWT�(S)LAST.FIRST,AND MIDDLE NAME(S). DRIVERS UCENISE NO. DATE OF BETH(S)
STREET ADDRESS CRY COUNTY STATE ZIP CODE I I ..
, -J/ 2-5 7'°!t S'1. 4/0 /V.,1.. g &I/0114 Wits it Ye9 mod ,3-1-01-01-
NAME OF NSURANCE CQ PO ICV NRNTBE< 79EMN�,E NQ
► f J.°f,i :i C°`c 0,176f l/.31- '/742
B ► IS-THS VEHICLE`SUBJEdt TO SECURITY AGREEMENT(S)? YES 1 I NO IF YES,COMPLETE SECTION BELOW
FEST SECURED PARTY(PRM NAME) DATE OF LOAN
PURCHASER(S)
CMWHERST) STREET ADDRESS CITY STATE ZIP CODEMUCOMPLETE
LOAN SECOND SECURED PARTY(PENN NAME) DATE OF LOAN FOR ADOTT OVAL SECURED PARTIES,
information ATTACH COMPLETED FORM NO.PS2017.
STREET ADDRESS CITY STATE ZR CODE
C NoMILES(NO TENTHS) ODOMETER STATEMENT AND ASSIGNMENT BY SELLER(SEE WARNING ON BACK OF LAST PAGE)
I(WE)THE OWNER(S)OF THE VEHICLE DESCRIED ABOVE,CERTIFY THE ODOMETER ON THE VEHICLE NOW READS THE MIRES AS SHOWN ON THE LEFT
SELLER(S) 0 AND THAT TO THE BEST OF MY(OUR)KNOWLEDGE THAT R REFLECTS THE ACTUAL MILEAGE Of THE VEHICLE DESCRIED ABOVE UNLESS ONE OF THE
MUST FOLLOWING STATEMENTS IS CHECKED.
I(WE)THE OWNER(S)OF THIS VEHICLE CERTIFY THE VEHICLE IS FREE OF ALL SECURITY INTERESTS.WARRANT
COMPLETE TITLE'ASSIGN THE VEHICLE AND TAXES PAD TO THE PERSON(S)NAMED ABOVE.
AND ❑ (I)I HEREBY CERTIFY TO THE BEST Of MY KNOWLEDGE THE ODOMETER READNG REFLECTS THE AMOUNT OF MILEAGE IN EXCESS Of ITS MECHANICAL LIMITS
SIGN ❑ (2)I HEREBY CERTIFY THAT THE ODOMETER READING IS NOT THE ACTUAL MILEAGE,WARNING—ODOMETER DISCREPANCY IF BOX(1)OR(2)IS CHECKED.
► DAMAGE DISCLOSURE STATEMENT. TO THE BEST OF MY KNOWLEDGE THIS VEHICLE 0 HAS 0 HAS NOT(CHECK ONE)SUSTAINED DAMAGE IN EXCESS OF 70%ACTUAL CASH VALUE
P. POLLUTION SYSTEM DISCLOSURE STATEMENT. TO THE BEST OF MY KNOWLEDGE THE POLLUTION CONTROL SYSTEM ON THIS VEHICLE INCLUDING THE RESTRICTED GASOLINE PIPE
0 HAS ❑ HAS NOT(CHECK ONE)BEEN REMOVED,ALTERED OR RENDERED INOPERATIVE.
SELLERS PRINTED NAMES) DATE
SELLER'S STREET ADDRESS cm STATE VP
X
MrgaiarMa
PURCHASER'S EXCISE(SALES)TAX DECLARATION BASE YAMS oR REGISTRATION TAX+ $ t
D
1 FULL PURCHASE PRICE $ < �WGHL PLATE FEE
PURCHASERS) RATIO N PE IOD ARREARS TAX
2 LEE PR
SS TRADE-IN ALLOWANCE
OWNER(S) COMPLETE ITEM NO 6 FROM TO CONVERSION FEE
MUST
COMPLETECHANGE OF GROSS VEHICLE WEIGHT
3.NET PURCHASE PRICE TIME Of
AND ��/ CHANGE NOURS TRANSFER TAX
SIGN 4.—51/OF LEE 3.../Y n..
& LESS TAX PAID ANOTHER
TO / STATE DATE aI I TITLE/TRANSFER FEE g EXCISE TAX DUE $ C CHANGE EXCISE TAX
6 TRADE WAS A; MAKE PLATE NUMBER DATE LATE TRANSFER PENALTY
MODEL YEAR CHANGE
EXPIRES SUB-TOTAL$ <.
CHANGE OF WGT.AND/OR CLASS STATE/DEPUTY FIUNG FEE :2
I DECLARE IA NUMBERPROAL TO J
THIS TAX // TOTAL DUE S
I RR�Lvv�E CONY t I/1 AM WE)OP ILEAL AOC EEkUMIT THIS MEW 3":51)
EXEMPTION CODE N6RCr i0 CADS Aw NG oihns,TNB vtNpL R Aw wu
CONRAR TO N INRRW WIRE OPE ATN6 LION TIE NRIC 67E@T6
NOTARY SIGNATURE SUBSCRIBED AND SWORN TO BEFORE ME. DATE ANO 111OIIWAY6.THE VEHICLE WAS N OPERATED M COMPLMNCE WITH
TIE LAWS WHICH APPLY TO as CIASS OP NG67RATION,HAVE NCOVW iil
A COPY OP TOSS APPLICATION AND AU Of MY DECLARATIONS +
AN TWE AND CORNCT.I(W!)RRHH CUVY TIDY F HN I6 A COMPARE. �!
CW TESTIS I(WE)HAVE KNOWIMOE Oi STATE MD RDREAI RLWLA. Eft'
COUNTY DATE MY COMMISSION EXPIRES URS,CHANTER 221,mew SERVICE coMMSSOCOMMIXIAL WWII ION HAIR T THIOU TO*MINNESOTA Ea. 0-7/-z J-Cw,{A
AND CODE Of FEDERAL Rf01MTION6,TIDE A9.PARTS 390 THROUGH x � `• � i,/
199.ANDFA TRAWPORTRE OPISAZARDOL6MATEIAILCODEOP FEDERAL
REGULATIONS,TOLE 19.PARTS 171 TO 199,
SIGNATURE(S)(ALL PURCHASERS )MUST SIGN) DATE
DEPARTMENT OF PUBLIC SAFETY DO NOT SIGN UNTIL COMPLETED
DRIVER AND VEHICLE SERVICES DIVISION,TRANSPORTATION BLDGir
_ vs 2000-15
,,,R ,," ,,,,.,„„,,,.. 395 JOHN IRELAND BLVD.,ST.MDL,MN 55155 PURCHASER'S(OWNER'S COPY)
Total Gross Total Gross Total Gross Total Gross ,.
GROSS WEIGHTWeight Code Weight Code Weight Code Weight Code' , 3
BRACKETS
AND 0 - 1,500 A 9,001 - 12,000 F 27,001 - 33,000 K 57,001 - 63,000 P
.
CODES 1,501 - 3,000 B 12,001 - 15,000 G 33,001 - 39,000 L 63,001 - 69,000 Q
3,001- 4,500 C 15,001 - 18,000 H 39,001 - 45,000 M 69,001 - 73,280 R
4,501 - 6,000 D 18,001 - 21,000 I 45,001 - 51,000 N 73,281 - 78,000 S
6,001 - 9,000 E 21,001 - 27,000 J 51,001 - 57,000 0 78,001 - 81,000 T
CLASSIC AUTOMOBILE The following cars built between and including 1925 and 1948 are "Classic Automobiles" with the exception of Lincoln Continentals,
INFORMATION which are"Classic"from 1939 through 1948.
A.C. ISOTTA FRASCHINI PEERLESS:
ADLER JAGUAR 1926 through 1928:Series 69
ALFA ROMEO JORDAN: 19304931:.Custom 8
ALVIS: Speedway Series"Z"only 1932:Deluxe:Custom.8
Speed 20,25 and 4.3 litre KISSELL: PIERCE ARROW
AMILCAR 1925, 1926 1927:Model 8-75' RAILTON
ASTON MARTIN 1928:Models 8-90&8-90 White•Eagle RENAULT:
AUBURN: 1929:Models 8-126&8-90 White Eagle Grand Sport model only
All 8&12 cylinder models 1930-1931:Model 8-126 REO:
AUDI LAGONDA 1930-1931:Royale Custom 8,
AUSTRO-DAIMLER LANCIA : .Series 8-35.&8-52 Elite 8
AVIONS VOISIN 12 LA SALLE: 1933:Royale Custom 8
BENTLEY 1927 through 1933 only REVERE
BLACKHAWK LINCOLN: ROAMER:
B.M.W.: All Models K,L, KA, &KB 1925:Series 8-88,6-54e&4-75
Models 327,328&335 only 1941:Model 168 H v 1926:Series 4-75e&8-88
BREWSTER: 1942:Model 268 H 1927-1928:Series 8-88
(Heart Front Ford) LINCOLN CONTINENTAL: 1929:Series 8-88&8-125
BUGATTI 1939 through 1948 1930:Series 8-125
BUICK LOCOMOBILE: ROHR
1931 through 1942:Series 90 only. All 48&90 models ROLLS ROYCE
CADILLAC: 1927:Model 8-80 RUXTON
All 1925 through 1935 models, 1936-1942: SALMSON
1928:Model 8-80
Series 67,70,72,75,80,85,&90 only. 1929:Model 8-80&8-88 SQUIRE
1938-1941:60 special only.
CHRYSLER: MARMON: STEARNS KNIGHT
1926 through 1930: Imperial 80 All 16 cylinder models STEVENS DURYEA
1931:Imperial 8 Series CG 1925:Model 74 STEYR
1932:Series CG&CL 1926:Model 74 STUTZ
1927:Model 75 SUNBEAM
1933:Series CL
1934-1935:Series CW 1928:Model E 75 TALBOT
All Newports&Thunderbolts 1930:Big 8 Model VAUXHALL:
CORD 1931:Models 88,and Big 8 Series 30-98 only
M
CUNNINGHAM AYBACH WILLS SAINT CLAIRE
DAGMAR: McFARLAN
Model 25-70 only MERCEDES BENZ:
DIAMLER All models 2.2 litres&up
DELAGE MERCER IMPORTANT!
DELAHAYE M.G.
DOBLE 6 cylinder models only
DORRIS MINERVA No commercial vehicles such as
DUESENBERG PACKARD: hearses,ambulances or trucks are
du PONT 1925 through 1934,all models. 1935-1942: considered to be "Classic"
FRANKLIN: Models 1200, 1201, 1202, 1203, 1204, 1205, Automobiles".
All models except 1933-34 1207, 1208, 1400, 1401, 1402, 1403, 1404,
Olympic Sixes 1405, 1407, 1408, 1500, 1501, 1502' The foregoing list is all inclusive.
. FRAZER-NASH 1506,1507, 1508, 1603, 1604, 1605, 1607, No other vehicles can be
HISPANO SUIZA 1608, 1705, 1707, 1708, 1806, 1807,1808, registered as "Classic Auto-
HORCH 1906, 1907,1908,2006,2007,&2008 only mobiles".
HOTCHKISS 1946 and 1947:Models 2106 and
2126 only.
INVICTA
All data collected on a motor vehicle application, with the exception of your home telephone
number,are required by law.These data are used to identify your motor vehicle. Failure to provide
required data may result in denial of the transfer of ownership, registration of this vehicle,or other
requested action. Except for excise (sales) tax data, your motor vehicle record is public and
transcripts may be issued to anyone.
APPLICATION TO TITLE/REG. A VEHICLE PLATE NUMBER YEAR FOR VAUOATION AND OFFICE'USE ONLY
'_ FOR CENTRAL OFFICE USE ONLY
STICKER NUMBER YEAR rip /T.2 1 L
DEC 1 01992
TLE TITLE REG REG TER PREVIOUS PLATE NUMBER YEAR MONTH YEAR
A ® ONLY MY CHANGE EXPIRATION
DATE ry_
DE-PlJ L I P-,C;.,;R.dy 1 NAR#8.5#8.5TI
PURCHASER(S) DATE OF PURCHASE CHECK GAsaRR NATURAL GAS I
OWNER(S) l iJ` t,`. NEW \i/USED FURL I oR PI00PANE -NASHIN�G TON COUNTY
MUST es.s .f TYPE DIESEL OTHER- ,,
COMPLETE MODEL YEAR MAKE/ BODY/MODEL TYPE
vehide 110. 13 i D
information C'..- /to oe /` //feew d
VEHICLE IDENTIFICATION NUMBER f)
,e1 Co / .0 5 37 YT'Fir✓/10 .., 2c? COLOR
CODE
BODY ROOF
PURCHASERS) ►LAST,FIRST,AND MIDDLE NAME,G, ( / r DRIVERS L NO. DATE OF BIRTH
OWNER()
information j Ty , f t..-CAt , '�j, K' 11 c t,, A•,f
ADDITIONAL PdRCWSEREf OWNER(S)LAST,FIRST,AND MIDDLE NAME(S)- DRIVERS LICENSE NG - DATE OF BIRTH(S)
STREET ADDRESSCy^ CITY ' COUNTY STATE2/1 CODE
R4-hlkek - :5 r/ - /, /Lf ( LX0/,:k') U,11 4. L0gs11 1,5/ J/hd 5--.01-;07-
NAME OF INSURANCE CG POLICY NUMBER HOME T
ELEPHONE NO,
If
=tG ) . . ii 39- 4/2.23
B ► IS THIS VEHICLE;SUBJECT TO SECURITY AGREEMENT(S)? W YES_ NO >ei IF YES,COMPLETE SECTION BELOW
FIRST SECURED PARTY(PRINT NAME) DATE OF LOAN
PURCHASER(S)
OWNERS) STREET ADDRESS CITY STATE ZIP CODE
MUST
COMPLETE
LOAN SECOND SECURED PARTY(PRINT NAME) DATE Of LOAN FOR ADDITIONAL SECURED PARTIES,
Information ATTACH COMPLETED FORM NO.PS2017.
STREET ADDRESS CITY STATE ZP CODE
C . MILES(NO TENTHS) ODOMETER STATEMENT AND ASSIGNMENT BY SELLER(SEE WARNING ON BACK OF LAST PAGE)
I(WE)THE OWNER(S)OF THE VEHICLE DESCRIBED ABOVE,CERTIFY THE ODOMETER ON THE VEHICLE NOW READS THE MILES AS SHOWN ON THE LEFT
SELLER(S) 0 AND THAT TO THE BEST OF MY(OUR)KNOWLEDGE THAT IT REFLECTS THE ACTUAL MILEAGE OF THE VEHICLE DESCRIBED ABOVE UNLESS ONE OF THE
FOLLOWING STATEMENTS IS CHECKED.I(WE)THE OWNER(S)OF THIS VEHICLE CERTIFY THE VEHICLE IS FREE OF ALL SECURITY INTERESTS,WARRANT
MUST TITLE,ASSIGN THE VEHICLE AND TAXES PAID TO THE PERSON(S)NAMED ABOVE.
COMPLETE
AND ❑ (1)I HEREBY CERTIFY TO THE BEST OF MY KNOWLEDGE THE ODOMETER READING REFLECTS THE AMOUNT OF MILEAGE IN EXCESS OF ITS MECHANICAL LIMITS. I
SIGN
(2)I HEREBY CERTIFY THAT THE ODOMETER READING IS NOT THE ACTUAL MILEAGE.WARNING—ODOMETER DISCREPANCY IF BOX(1)OR(Z)IS CHECKED.
► DAMAGE DISCLOSURE STATEMENT. TO THE BEST OF MY KNOWLEDGE THIS VEHICLE 0 HAS 0 HAS NOT(CHECK ONE)SUSTAINED DAMAGE IN EXCESS OF 70%ACTUAL CASH VALUE,
P. POLLUTION SYSTEM DISCLOSURE STATEMENT. TO THE BEST OF MY KNOWLEDGE THE POLLUTION CONTROL SYSTEM ON THIS VEHICLE INCLUDING THE RESTRICTED GASOLINE PIPE
0 HAS 0 HAS NOT(CHECK ONE)BEEN REMOVED,ALTERED OR RENDERED INOPERATIVE.
00
SELLER'S PRINTED NAME(S) DATE
SELLER'S STREET ADDRESS CITY STATE ZP
gi
gillETIZMUlik
D PURCHASER'S EXCISE(SALES)TAX DECLARATION EASE V' oR REGISTRATION TAX+ $ a
$ C GROSS WOK
PLATE FEE
1, FULL PURCHASE.PRICE
PURCHASER(S) REGISTRATION PERIOD ARREARS TAX
4. LESS TRADE-IN ALLOWANCE
OWNER(S) COMPLETE ITEM NO.6 FROM TO CONVERSION FEE
MUST
COMPLETE CHANGE OF GROSS VEHICLE WEIGHT
3.NET PURCHASE PRICE TIME OF
ANDSINN 4_%OF LINE 3.../(14,, • RS
CHANGE • TRANSFER TAX
S. LESS TAX PAID TO ANOTHER STATA TITLE/TRANSFER FEETE DATE OF / R'0
NET EXCISE TAX DUE $ IT CHANGE I I EXCISE TAX
6.TRADE-IN WAS A: MAKE PLATE NUMBER DATE LATE TRANSFER PENALTY
MODEL YEAR CHANGE
EXPIRES SUB-TOTAL$ a
CHAS OF WGT.AND/OR CLASS STATE/DEPUTY FILING FEE - 3 p
FROM TO 1(
I DECLARE ID.NUMBER TOTAL DUE$
THIS TAX
EXEMPTION CODE /f I t ar 1 DvEWowM NEA1NaD NOG0OIA0K NDSE VG E S WEEILTL '"" J /5
COMMAS TO OE SINEW WIRE OPERATING UPON THE PUBLIC STREETS
NOTARY SIGNATURE SUBSCRIBED AND SWORN TO BEFORE ME.
DATE APL LIG WAYS,THE VUKCES WEE BE OPRIATED N COMrwNCE WITH �''
TIE LAWS WHIN APPLY TO OS CEASE OP RG%TRATION,HAVE RECUVED Yft"^
A COPY OF TIES APPLICATION AND AR OF MY OIM��DECURATKMIB
ARE TRUE AND CORRECT.IIWEIFU EDG CLRfST THAT P TIME IS A COMARE•
CIAL VEHICLE 119[)HAVE KNOWLEDGE OF STATE AND PERUSAL REOULA.
1TUS,CH TER 2210 URIC SERVICE CNMMISSIOATI011,MI TIROIA 6TAT. _`-.` v � /�Q,
COUNTY DATE MY COMMISSION EXPIRES AND
CHAPTES 221,ILBLK SERVICE PE,T COMMISSION RIMS 1 THROUGH 4e, "-.'lr 1FLw'J:! 7
AND CODE Of FEDERAL REGULATIONS,TITLE A PARTE 390 THROWNx
399,AND If A TRANSPORTER Of NAZARDOUS MATERIALS,CODE Of FEDERAL
REGULATIONS,TITLE 49,PARTS 171 TO 199.
SIGNATURE(S)(ALL PURCHASERS OWNS S)MUST SIGN) DATE 1
topsMINNESOTA DEPARTMENT OF PUBLIC SAFETY DO NOT SIGN UNTIL COMPLETED
DRIVER AND VEHICLE SERVICES DIVISION,TRANSPORTATION BLDG- -
395 JOHN IRELAND BLVD.,ST.PAUL,MN 55155
AN MUM.ONDATUMITY.MROY..
PS 2000.15 SELLER'S COPY
. iY : ) lei U3>{ ', :G, 4.—). ^i:4;1h`, pI'
SELLER(S) MUST COMPLETE Ell
PURCHASER(S) (OWNER) MUST COMPLETE A B D , AND M.
PURCHASER(S) (OWNER'S)MUST ALSO COMPLETE:
WHEN REGISTERING A VEHICLE FROM ANOTHER STATE
WHEN UNDER LEGAL AGE.
WHEN A WAIVER OF INSURANCE(NO FAULT)CERTIFICATION IS NEEDED.
DATA PRIVACY INFORMATION .. •
All data collected on a motor vehicle application, with the exception of your home telephone number, are required by law. These data are
. used to identify your motor vehicle. Failure to provide required data may result in denial of the transfer of ownership, registration of this
. vehicle, or other requested action. Except for excise (sales) tax data, your motor vehicle record is public and transcripts may be.issued..to
anyone.
BEFORE COMPLETING AQ, Oa D PLEASE READ.CAREFULLY
A BLACK D GRAY C MAROON L SILVER
VEHICLE COLOR CODES BLDE GREEN G ORANGE 0 TAN H-
BROWN E IVORY I PINK J WHITE F
GOLD N LAVENDER M RED A YELLOW K
OWNERSHIP INFORMATION
WHEN THIS VEHICLE IS TRANSFERRED, ALL( OWNERS MUST
A SIGN THE ASSIGNMENT IF THE VEHCLE IS OWNED AS JOINT TENANTS (OR-AND/OR)
OR AS TENANTS IN COMMON WHEN THE VETITLE BY THE H C E S ONG WN DINT�Y ANT SOOLEN WN RITLE E OR BY TENANTS S AND IN COPRIATE OMMON P PROOF OS ARE REQUIRED.ATH,ASSIGNMTHE ENTT OF THE DEATH OF TO A SURVIVORAND-NO CONJUNCTION).IN THE EVENT OF THE DEATH OF A JOINT TENANT,PROOF OF DEATH, AN PROBATE
CATION OWNER
COURPRIA ETFEES IF ARE REQUIREDATE IS .PROR BY OBATED
VEHICLE SVIT LEAOF NO SED FORMORE THAN APPLICATION AN CERTFICATE)AND APPRO-
PRIATE
PPRO
180 DAYS A FORM(PS 0 9-01 MUSTT BE ATTACHED.
13 ODOMETER (MILEAGE) STATEMENT MUST BE SIGNED BY ALL SELLERS (SEE OWNERSHIP INFORMATION ABOVE)
WARNING
YOU ARE REQUIRED BY LAW TO DISCLOSE THE ACTUAL ODOMETER READING AT THE TIME OF TRANSFER.ANY FALSE STATEMENT MAY MAKE YOU LIABLE FOR CML AND
CRIMINAL PENALTIES PURSUANT TO THE FEDERAL MOTOR VEHICLE INFORMATION AND COST SAVINGS ACT AND MINNESOTA LAWS 1973,CHAPTER 264 AND 1977
CHAPTER 105.
AN ODOMETER STATEMENT IS NOT REQUIRED FOR:
1. A VEHICLE HAVING A GROSS VEHICLE WEIGHT RATING OF MORE THAN 16,000 POUNDS;
2. A VEHICLE THAT IS NOT SELF-PROPELLED;OR
3. A VEHICLE THAT IS 10 YEARS OW OR OLDER.
D MUST BE SIGNED BY ALL PURCHASERS (OWNERS).
EXCISE (SALES) TAX EXEMPTIONS AND CODES
(MS. 2978.01 Sub. 8)
" EXEMPTIONS CAN BE USED ONLY AS LISTED. NO CHANGES MAY BE MADE!
WHEN A VEHICLE IS ACQUIRED FOR NOMINAL OR NO MONETARY CONSIDERATION,TAX MUST BE BASED ON THE.AVERAGE VALUE OF-SMAEAR VI3IICLES.
CODE EXEMPTION CODE EXEMPTION
1. VEHICLE WAS A GIFT BETWEEN HUSBAND AND WIFE OR PARENT AND CHILD OR THE VOLUN- 5. PURCHASER WAS A NONRESIDENT WHEN VEHICLE WAS PURCHASED AND SUBSEQUENTLY
TARY OR INVOLUNTARY TRANSFER OF A MOTOR VEHICLE BETWEEN A HUSBAND AND WIFE BECAME A RESIDENT OF MINNESOTA MORE.THAN 60 DAYS AFTER THE DATE THE VEHICLE
IN A DIVORCE PROCEEDING.THIS EXEMPTION WOULD ALSO APPLY IN THE CASE OF A TRANS- WAS TITLED IN ANOTHER STATE
FER FROM GUARDIAN TO HIS WARD WHEN THERE IS NO MONETARY CONSIDERATION AND
THE TITLE TO SUCH VEHICLE WAS REGISTERED IN THE NAME OF THE GUARDIAN AS GUARD- 6. THE PURCHASER IS A DISABLED VETERAN PURCHASING WITH FUNDS PROVIDED BY THE VET-
IAN,ONLY BECAUSE THE WARD WAS A MINOR. ERANS ADMINISTRATION UNDER THE PROVISIONS OF TITLE 38.
2. VEHICLE WAS ACQUIRED BY INHERITANCE,BEQUEST OR BY SELECTION BY SURVIVING SPOUSE. 7. PURCHASER IS AN INTERSTATE CARRIER HOLDING A COMMON CARRIER DIRECT PAY CERTIFI-
CATE.GIVE NUMBER.PRORATE VEHICLES ONLY.
3. VEHICLE IS FOR RESALE BY PURCHASER WHO HOLDS SALES AND USE TAX ACCOUNT NUMBER.
THIS APPLIES TO LENDING INSTITUTIONS AND INSURANCE COMPANIES ONLY.GIVE NUMBER. 8. VEHICLE IS FOR RESALE OR LEASE BY A LICENSED MINNESOTA DEALER OR LESSOR WHO
HAS A MINNESOTA DEALERS LICENSE NUMBER.GIVE NUMBER.
4. VEHICLE WAS TRANSFERRED FROM JOINT OWNERSHIP TO OWNERSHIP BY ONE OR MORE
OF THE SAME JOINT OWNERS WITHOUT MONETARY CONSIDERATION,OR THE VEHICLE 9. PURCHASE OF A MOTOR VEHICLE BY A PRIVATE NONPROFIT OR PUBLIC EDUCATIONAL INSTI-
WHICH WAS/IS REGISTERED IN MINNESOTA WAS TRANSFERRED TO A.CORPORATION OR TUTION FOR USE AS AN INSTRUCTIONAL AID IN AUTOMOTIVE TRAINING PROGRAMS OP-
A PARTNERSHIP IN EXCHANGE FOR STOCK OR SECURITIES OR AN INTEREST IN THE PARTNER- ERATED BY THE INSTITUTION.
SHIP.
10. THE VEHICLE ISA MUNICIPAL FIRE APPARATUS,MARKED PATROL CAR,MUNICIPAL AMBULANCE,
THE GENERAL APPEARANCE OF WHICH IS UNMISTAKABLE PURCHASE OF AN AMBULANCE
BY A LICENSED AMBULANCE SERVICE
THE ONLY TRADE-IN ACCEPTABLE FOR REDUCTION OF PURCHASE PRICE IS ANOTHER REGISTERED OR PREVIOUSLY REGISTERED -
MOTOR VEHICLE.FARM EQUIPMENT,FURNITURE,ANIMALS,ETC.CANNOT BE LISTED AS A TRADE-IN.
ANY PERSON WHO SHALL COMPLETE OR SUBMIT A FALSE OR FRAUDULENT MOTOR VEHICLE PURCHASERS CERTIFICATE WITH INTENT TO DEFEAT OR EVADE
PAYMENT OF EXCISE TAX SHALL BE GUILTY OF A MISDEMEANOR AND FOR EACH SUCH OFFENSE SHALL BE FINED NOT MORE THAN$500.00 OR BE IMPRISIONED
IN THE COUNTY JAIL FOR NOT MORE THAN ONE YEAR OR BOTH.
TO DETERMINE ANY VARIABLE TAX AMOUNT AND/OR FEES OR TO OBTAIN
ASSISTANCE IN COMPLETING THIS APPLICATION,CONTACT
A DEPUTY REGISTRAR OF THE DEPARTMENT OF PUBLIC SAFETY,DIVISION OF DRIVER AND VEHICLE SERVICES
ADVERTISING
DFAI. // 145
hone HQwkins
• CItSTOP"F � 'Y166AFTHOMAS
SALESMAN (TYPE)
(NAME)
• ar Chevr�ole Geo iMQZdQ, inc
. DATE 12,10,92
STOCK# 32411
- 1801 E. Cty. Rd. F WHITE BEAR LAKE, MN. 55110 (612) 429-7791 INS CO. LEAGUE OF MINNESOTA CI
POLICY# CMC 12802
IUYER'S CO-BUYER
LAME CITY OF OAR PARK HEIGHTS NAME
IUYER'S CO-BUYER'S DOB •
)RIVERS LIG#" DOB DRIVERS LIC. #
iTREET RESIDENCE
1DDRESS 14168 57TH STREET NORTI? PHONE -
,IT ,STATE BUSINESS
;O NTY,ZIP OAK PARK TITS ( WASHINGTON ) MN 54082 PHONE (612)4139-1039
PLEASE ENTER MY ORDER FOR A 4IIge 9'1 CTIEVP.OLP, S110 ilg-(o.EL) ! ' ' (BODY TYPE)
DEMO (YEAR AND MAKE)
LICENSE
COLOR BODY SPECIAL COL/390F TRIM BLI1E f^T /VN SERIAL NO. 1G111L537XPtU)0379 '
CASH DELIVERED PRICE OF UNIT $ NON GM LOCALLY INSTALLED OPTIONS $
FREIGHT fl # T. s IA1°c nTd
OPTIONS AS PER WINDOG1 STICKER
P.TT.T.TNG TNVn
T• _ -_ •F UNIT $ 13074.00
TRADE IN YR. N/A MAKE N/A
- MODEL AND EQUIP.
TRADE IN ALLOW.AND DISC. $ NONE
BALANCE $ 13074.00
LOCAL DEALER HANDLING AND ADJUSTMENTS $ INCLUDED`:,
RUSTPROOFING YES NO XX $
PAINT SEALANT YES NO XX $
FABRIC PROTECTOR YES NO XX $
BALANCE $
SALES TAX $ 849.81
LICENSE_._ -$ -
DOCUMENT ADMINISTRATION FEE $ 25X��XX
RECORDING/TRANSFER + CERTIFICATION-FEES $
BALANCES $ 1 39 23.R I
kPl R XXC ATE DPS N/A $ $49.94
SERVICE CONTRACT YES NO $
NONE
DUPLICATE TITLE FEES $ X ` XX
Transferor(Dealer)hereby certifies,to the best of his/her knowledge,that the pollution
control system on this vehicle being sold, including the gasoline pipe, has not been BALANCE DUE ON DELIVERY $ 13074.00
removed,altered,or rendered inoperative. _ j
DEALER'S DISCLAIMER OF WARRANTY
The Healer expressly disclaims all wairanties, either express or implied on the vehicle sold,
except any warranties offered and explained in Paragraphs 10 through 13 on the back of this k contract. Buyer acknowledges receiving this information before the sale and further acknow- (.0 N ' A, AA ..1'•
ledges having read and understood the provisionson.the back of this contract. CUSTOMER SIGNATURE
The front and back of this CONTRACT comprise the entire CONTRACT affecting this purchase.The DEALER will not recognize any verbal agreement,or any other agreement or
understanding of any nature.You certify that no credit has been extended by dealer for the purchase of this motor VEHICLE.You certify that you are 18 years of age or older,and
acknowledge receiving a copy of this contract.
The terms of this NTRACT were agreed upon d the CONTRACT signed in this IMPORTANT: THIS MAYBE A BINDING CONTRACT AND
dealership on the
lib
at top . this form. A R is arranging credit for YOU,this YOU MAY LOSE ANY D 'OSITS IF YOU DO NOT PER—
CONTRACT is not v d until a cre- t.isclosur s mad s described in Regulation Z and you FORM ACCORDING 4ITS TERMS. CUSTOMERS)
nave accepted the ed :xtend .. AUTHORIZESDEAL-R' % = INACONSUM RNOTICE OF SALE' E` rI''S 'I' D ''HO- 'his c tract is not valid unless signed andCREDITREPORTIN ,� , �' WITEFINANCINGaccepted by Sale. fi•er t alers, . ���// �,� �� OF THIS VEHICLE1
Accepted ) Burr's Signature Accepting Terms of Contract
...--
This ODOMETER DISCLOSURE STATEMENT and ASSIGNMENT Refers to Vehicle Being Sold
Federal and State law require that you state the mileage upon transfer of ownership.Failure to complete or providing a false statement may result in fines and/or imprisonment.
I(we), THANE HAWKINS POLAR CHEV.GEO MAZDA.INC. , the owner(s)of the vehicle described below,certify the vehicle is free of all security interests,
Transferor's Name Print)
warrant title,assign the vehicle and taxes paid to the person(s)named below and state that the odometer now reads 8 ((no tenths)miles and to the best of my knowledge that
it reflects the actual mileage of the vehicle,unless one of the following statements is checked.
0(1) I hereby certify to the best of my knowledge the odometer reading reflects the amount of mileage in excess of its mechanical limits.
ADDITIONAL TERMS AND CONDITIONS OF THIS VEHICLE PURCHASE CONTRACT
1. Definitions: As used in this CONTRACT, except provisions relating to the trade-in vehicle, "YOU" or "YOUR" means the buyer and
co-buyer. "I", "ME", or"MY"means the seller or dealer. "VEHICLE"means the car,truck, or other VEHICLE described on the front of this
CONTRACT including all the options listed. "Manufacturer" means the company which makes the VEHICLE. "Trade-In" means the car,
truck, motorcycle or other vehicle which YOU trade to ME in partial payment for the VEHICLE.
2. Purpose: By signing the CONTRACT, YOU agree to buy the VEHICLE from ME. By accepting this CONTRACT, I agree to deliver the
VEHICLE to YOU if the VEHICLE is in MY inventory. If the VEHICLE is not in MY inventory, I agree to order the VEHICLE from the
manufacturer, and after receiving the VEHICLE from the manufacturer,to deliver the VEHICLE to YOU.
3.Price Changes by the Manufacturer: The VEHICLE price stated on the other side of this CONTRACT is based on the current prices
the manufacturer charges ME. At any time before I receive the VEHICLE from the manufacturer, the manufacturer has the right to'raise
the price it charges to ME. If the manufacturer does raise the price, I may raise the price to YOU by the same amount. If I do raise MY
price, YOU may cancel the CONTRACT and get back any downpayment YOU have made. If I have not already sold the Trade-In (See
Paragraph 4),YOU may have the Trade-In back by paying ME the reasonable cost of storage and any repair work or reconditioning I may
have done.
4.Trade-In: If YOU are using a Trade-In to partially pay for the VEHICLE,YOU may deliver the Trade-In to ME either when YOU sign this
CONTRACT or when the VEHICLE is ready for YOU to pick up. If YOU do not deliver the Trade-In to ME when YOU sign this CONTRACT,
YOU agree that at the time YOU deliver the Trade-In, I May reinspect the Trade-In and lower the allowance stated on the front of this
CONTRACT. If I do lower the allowance, YOU may cancel this CONTRACT and get back your cash downpayment.
If YOU deliver the Trade-In when YOU sign this CONTRACT, I may sell the Trade-In at any time and at any price I think proper. If this
CONTRACT is cancelled and I have already sold the Trade-In, I will pay YOU the price I received for the Trade-In minus 15%commission,
minus any money I spent repairing, storing, insuring or advertising the Trade-In, unless otherwise required by law.
5.Trade-In — YOUR Responsibilities:At the time YOU deliver the Trade-In to ME,YOU guarantee that YOU own the Trade-In free and
clear and agree to furnish proper proof of ownership, inlcuding the Certificate of Title or other evidence of ownership. If any outstanding
security interests are attached to the Trade-In vehicle, YOU are obligated to satisfy the debt secured and to obtain a release of all liens. If
I arrange payment of the debt,and the total amount is greater than the amount shown on this CONTRACT as the balance owing to lienholder,
YOU agree to pay the difference to ME in cash immediately upon notice of the deficiency. If the debt is less than the amount shown, I will
refund the surplus to YOU.
6.YOUR Refusal to Take Delivery: Unless this CONTRACT is non-binding because I am arranging credit for YOU,or unless YOU have
cancelled this CONTRACT pursuant to paragraphs 3 or 4, I will retain the cash downpayment YOU have given ME as an offset to MY
damages if YOU refuse to complete the purchase. YOU will also be responsible for any other damages which I may incur as a result of
YOUR failure to perform YOUR obligations under the terms of this CONTRACT.If YOU have delivered the Trade-In to ME at the time YOU
signed this CONTRACT, I may retain the Trade-In and sell it to reimburse MYSELF for the expenses of repairing,storing,or reconditioning
the Trade-In and for other expenses or losses I may incur as a result of YOUR failure to perform YOUR obligations under this CONTRACT.
7.Design Changes by the Manufacturer:The manufacturer has the right to change the design of the VEHICLE, its chassis, its parts or
accessories at any time without notice to YOU or to ME. In the event of a change in design, I have no duty to YOU except to deliver the
VEHICLE as made by the manufacturer.
8. Delays in Delivery: I am not responsible for delays in delivery caused by the manufacturer, or by accidents, fires, or other causes
beyond MY control. I do not control the manufacturer and am not part of the manufacturer and do not work for the manufacturer.
9.Taxes:The price of the VEHICLE does not include Federal Taxes, State Sales or Excise Taxes or any other tax or governmental fee.
YOU must pay ME the proper amount of any tax or governmental fee which applies to this sale.
10.New VEHICLE Disclaimer of Warranties: If YOU are buying a new VEHICLE,the VEHICLE will come with a manufacturer's warranty
which is a promise from the manufacturer directly to YOU. Unless otherwise agreed in a separate document(see Paragraph 12 below), I
expressly disclaim all warranties, express or implied, including any implied warranty of merchantability or fitness for a particular purpose. I
sell the VEHICLE"AS IS"and make no guarantees of any kind about the VEHICLE's quality or performance.YOU have complete responsibility
and all the risk for any problems with the VEHICLE.
11. Used VEHICLE Disclaimer of Warranties: Except as may be provided in the Buyer's Guide Window Form and a separate warranty
document (see Paragraph 12 below), if YOU are purchasing a used VEHICLE, I expressly disclaim all warranties, express or implied,
including any implied warranty of merchantability or fitness for a particular purpose. I sell the VEHICLE "AS IS"and make no guarantees
of any kind about the VEHICLE's quality or performance. YOU have complete responsibility and all the risk for any problems with the
VEHICLE. I do not guarantee that the VEHICLE will pass an exhaust emissions inspection.
12. Dealer Warranty or Service Contract: If I give a warranty on a used VEHICLE or YOU purchase an extended service contract on a
new or used VEHICLE, I may not disclaim implied warranties of merchantability or fitness for a particular purpose.
13. Used VEHICLE Window Sticker Form: If YOU are purchasing a used VEHICLE or a demonstrator,the information YOU see on the
window form for this VEHICLE is part of this CONTRACT.Information on the window form overrides any contrary provisions in the CONTRACT
of sale.
MADA BOPL-9 C Copyright MADA SERVICES,INC.,3/91 Reorder from MADA SERVICES,INC.,277 University Ave.,St.Paul,MN 55103—(612)291-2400
S'�ThoneHowkins
ADVERTISING nr I' ' I''
IQI' CTIST�NEP # t 7166 nA1 T' rlui ,_,eaeYPEI
5 't ' ��ei Geo SALESMAN INAMEi
1 • inc. DATE 12/10/07 Mazda'
1801 E. Cty. Rd. F WHITE BEAR LAKE, MN.55110 (612)429-7791 STOCK# '°/ 1
INS CO. LSACUE OF til"Il'.:P^.p r;'
POLICY# C''!C 12802
BUYER'S CO-BUYER
NAME CITY OF OAP_ PARR HEIGHTS NAME
BUYER'S
DRIVERS LIC.# DOB RIVER
DER'S
STREET RIVERS LIC.# DOB
ADDRESS 14168 - 57TH STPEET NOP.TII RESIDENCE
CITY,STATE PHONE
COUNTY,ZIP OAK PARE HTS I 1r'9S11INCTON .) !1 y 5SRF.7 BUSINESS
� PHONE (F 1214 38-4 i 1e
PLEASE ENTER MY ORDER FORA DEMO (TEAR
93 C P.VRQf.RT CAR K p sar, Lt), ne grnAtt
(BODY TYPE)
(YEAR AND MAKE) TS ,,n
""'�
COLOR BODY ^ITC IAT. COLNPOF LICENSE
TRIM RT.1F c1 iat SERIAL NO. I GI RT5Z73'PvI)017n
CASH DELIVERED PRICE OF UNIT $ NON GM LOCALLY_INSTALLED OPTIONS $
FREIGHT
OPTIONS AS PER LIINDObl STICKER ,..,-15r) ^ T. s ^rrsnrf
-
PTT.1 T9C TM/ r
T UNIT $
11074.1"1
TRADE IN YR. D/A MAKE N/A
MODEL AND EQUIP.
TRADE IN ALLOW.AND DISC. •
$ ••
BALANCE $ 17074.0(1
LOCAL DEALER HANDLING AND ADJUSTMENTS $ INCLUDED
RUSTPROOFING YES NO XX $
PAINT SEALANT .YES NO1- $
FABRIC PROTECTOR YES NO—„ _ •
BALANCE $
SALES TAX WA 19074,^^
= 1d1_Rl
LICENSE $
DOCUMENT ADMINISTRATION FEE �y^D'C
�
RECORDING/TRANSFER+CERTIFICATION-FEES $ 2S 00"
dv
BALANCE $ 119 21 R I
grolismifitbATF. DPS M 440.-84 .
SERVICE CONTRACT YES NO $
Y.R')P
Transferor(Dealer)hereby certifies,to the best of his/her knowledge,that the pollution DUPLICATE TITLE FEES
control system on this vehicle being sold,including the gasoline pi $ Y&b�,Xv
removed,altered,or rendered inoperative. Pe has not been BALANCE DUE ON DELIVERY
$ 1397'fit'
O ALER•1#.DISCLAIMER OFFWARRANTY ' '
The Dealer expressly disclaims ail wetranlies 'either expre 'orimpaled brl ff e-vs siSOKe eo
except any warranties offered and explained in Paragraphs lethrough'13'en the back of this " n n -C A
contract.Buyer acknowledges receiving,alts information before the sale and further acknow- ,(3/ j .��Vv V\1�
ledges having read and understood the provisions on the back of this contract. .
CUSTOMER SIGNATURE
The front and back of this CONTRACT comprise the entire CONTRACT affecting this purchase.The DEALER will not recognize any verbal agreement,or any other agreement or
understanding of any nature.You certify that no credit has been extended by dealer for the purchase of this motor VEHICLE.You certify that you are 18 years of age or older,and
acknowledge receiving a copy of this contract.
The terms of this NTRACT were agreed upo d the CONTRACT signed In this IMPORTANT:THIS MAY BE A BINDING CONTRACT AND
dealership on the da noted at top• this form. A R Is arranging credit for YOU,this
CONTRACT Is not v d until a cre, •isclosur a mad s described In Regulation Z and you YOU MAY LOSE ANY D OSIT8 IF YOU DO NOT PER-
CONTRACT
accepted the ed xtend • FORM ACCORDING n ITS TERMS. CUSTOMERS)
NOTICE OF SALE:.• 'S - • D HO' ,/his c••tract is not valid unless signed and AUTHORIZES DEAL=-- A•, • • ' IN A CONSUMER
accepted by Sale.' %�, r e'er:7. ,. / CREDIT REPORT IN •"`" • yyl• T E FINANCING
Accepted-X: ,0 .. /� (.�mg 4 {'tom
-...---—
Bu-r Signature Accepting Terms of Contract
This ODOMETER DISCLOSURE STATEMENT and ASSIGNMENT Refers to Vehicle Being Sold
Federal and State law require that
Q you state the mileage upon transfer of ownership.Failure to complete or providing a false statement may result in lines andJor'imprisonment.
I(we), THANE HAWKINS POLAR CHEV.GEO MAZDA,INC. ,the owner(s)of the vehicle described below,certify the vehicle is free of all security interests.
Transferor's Name Print)
warrant title,assign the vehicle and taxes paid to the person(s)named below and state that the odometer now reads R
it reflects the actual mileage of the vehicle,unless one of the following statements is checked,it tenths)miles and to the best of my knowledge that
El(1)I hereby certify to the best of my knowledge the odometer reading reflects the amount of mileage in excess of its mechanical limits.
O(2)I hereby certify that the odometer reading is NOT the actual mileage.
WARNING ...
r�[1f d �/iY4= caGtx(t)of{?1 is checked.
A lit \••'��IS�YS'i' 1 I SODT TYPE
v 4 P.P SFnAPI
TR t v fs Y •1.0‘ 1r�/�'1,79. ) re � I LC.EXP.DATE
o l• M..1{ HEIGHTS TRANSFE •-'S(SELLE: •TREET AD SS
Apgq� M 7
STREyT ApggEgs 57Th STRF,R,'1' NORTH
CITY 1 " STATE I
clrvrlA PARK HTS� /f� <STTE ZIP �w ' ' '_
j � , fiN 55082 TR iTlp-i ' r LER)r{`NA•o '/� •'r NERS NAME ALSO/
$b11g
TRANSFEREE'S(BUYER)SIGNATURI(P IN EAAi�A4 1I ( �,/ ,�.19 /
Receipt of copy acknowiedged ` I STATEMENT DATE
17/11(/,.7
APYLILAIIUN IU IIILt/KtL.i.A Vti'1ILLt ' -
- FOR CENTRAL OFFICE USE ONLY
ti L!d II C -t
STICKER NLMEER YEAR ,?.' i
TITLE TITLE REG REG TPR PREVIOUS PLATE NURSER YEAR MONTH YEAR i P P f 1 1-1
A S REG ONLY ONLY 04NO1 EXPIATION �"
DATE .. .
PURCHASER(S) DATE OP PURCHASE OM I,E oPITUOPP '. ..1: .-.
CNNER(S) / �j REED USED ►� —
MUST ��— ` 9 TY►E I °` once WA'...,' -R.^`. _':: -te..::;
COMPLETE MODEL YEAR MAKE EDDY/MODEL TYPE 07
vane'le _ T NOPMNIGOTURLE R�E$TGAISAT�READTION RECENT(CARD)ANON TIC UPPER RIGIG BD CA CARD)
information �� eV-ley �j4�/�Id', �v THISWHEN COPY
OR THE CENTRAL WLL SERVE EVIDENCE OF
venal IDENTIFICATION NUMBER TAX THE AIDDEsT HAVE ASSIGNED TOTTPE OWNER POOR PLATES TIOWN C
�7` 'P'�1/O ? cam RODY Roo,
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ISI
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Information
ADDITIONAL OWPER(S)LAST.FEST.MO MOW NAMF(5)• DENNIS LICENSE NO. 'DATE OP NUM)
STREIT ADDREESS ..��( `, -CITY 1. / /COUNTY (1�7 STATE ZIP CODE
14/(05)-.J/_, :�.I. Ala tat i /'AK k NI N 1-4 Lths h gc9. /!/N .3-7,-A
NAME OP INSURANCE CO POKY NIYANR - E TLSMIONE NO.
► f .. - r R- R; IAA,,,:, ele:147, Gm& VV .39- y7a
B ► IS�THfS VEHICLEFSUBJECT TO SECURITY AGREEMENT(S)? YES I NOYES,COMPLETE SECTION BELOW.
FIST SECURED PARTY(PENT NAME) DATE OF LOAN
PURCHASER(S)
PNE(5) STREET ADDRESS CITY STATE VP CODE
MUST •
COMPLETE
LOAN
SECOND SECURED PARTY(PRM NAME) DATE OF LOAN FOR ADOITIONAL SECURED PARTES,
Information ATTACH COMPLETED FORM NO.PS2017.
STREET ADDRESS CRY STATE Z•CADS
C MLES(NO TENTHS) ODOMETER STATEMENT AND ASSIGNMENT BY SELLER (SEE WARNING ON BACK OF LAST PAGE)
► I(WE)THE OWNER(S)OP THE VEHICLE DESCRIBED ABOVE.CERTIFY THE ODOMETER ON THE VEHICLE NOW READS TIE MUS AS SHOWN ON THE LEFT
SELLER(S) D AND THAT TO THE MST OF OF THE VEHICLE DESCRIBED MOVE UNLESS ONE OF THE
FOLLOWING STATEMENTS ISNTC I�OWNER(S) TTHAT IT HIS VEHICLE CERTFYTHE ACTUAL E THE VEHICLE IS FREE OF AIL SECURITY INTERESTS.WARRANT
MUST TITLE.ASSIGN THE VEHICLE AND TAXES PAD TO THE PERSON(S)NAMED ABOVE.
COMPLETE ❑ (1)1 HEREBY CERTIFY TO THE BEST OP MY KNOWLEDGE THE ODOMETER READING REFLECTS THE AMOUNT OF MILEAGE N EXCESS OF ITS MECHANICAL AL UMITS
Atm
SIGN 0 (2)I HEREBY CERTF(THAT THE ODOMETER READNG IS NOT THE ACTUAL MILEAGE WARNING—ODOMETER DISCREPANCY IF BOX(1)OR(2)IS CHECKED.
► DAMAGE DISCLOSURE STATEMENT. TO THE BEST OF MY KNOWLEDGE THIS VEHICLE 0 HAS 0 HAS NOT(CHECK ONE)SUSTAINED DAMAGE N EXCESS OF 70%ACTUAL CASH VALUE
P. POLLUTION SYSTEM DISCLOSURE STATEMENT. TO THE ZEST Of MY KNOWLEDGE THE POLLUTION CONTROL SYSTEM ON THIS NUKES NCWCI4G THE RESTRICTED GASOLINE PIPE
0 HAS 0 HAS NOT(DECK ONE)BEE11 REMOVED,ALTER OR RENDEREDINOPERATIVE
P.
SMELTS MISTED NAME(S) DATE
Dual STREET ADDRESS CITY STATE ZP
PURCHASER'S EXCISE(SALES)TAX DECLARATION BAN VALUE OR REGISTRATION TAX+ $ S
D s R GROSS WOK PLATE FEE
1.FULL PURCHASE PRICE
PURCHASERS) a Lana TRADFRV ALLOWANCE RIOGIRATION PERIOD ARREARS TAX
OWT'Et(S) COMPLETE ITEM NO.6 FROM iO CONVERSION FEE
MUST CHANCE OP GROSS VDICLE WEIGHT .
COMPLETE i NET PURCHASE PRICE TLIE OP
TRANSFER TAX
SAIGON a_x co LINE 3...N .. CHANGE TITLE/TRANSFER FEE
3.LESS TAX PAD TO ANOTHER SPATE OATS a g
NET EXCISE TAX DIE $ S CHANGE I I EXCISE TAX
A TRACIJS WAR A: MAKE PLATE WANG DATE LATE TRANSFER PENALTY
Moon YEAR CHANGE
MISS I I SEN;-TOTAL$ R
cIULPIOE OP`"�A"D/OR cLAsS STATE/DEPUTY FERNG FEE 3
MOM TO
I DECLARE ID.NUMMI TOTAL DUE$
TMS TAX /` MCI
ONVL l LAR AM ITMI 15CM UDE.wwt EO1mrt TIM D WU 5'
EXEMPTION CODE U COM p IOi* W4 MO NO 0110•1 00 Y5 E IL AW ALL
NOTARY SIGNATURE SUBSCRIBED AND SWORN TO BEFORE ME DATE
CmO OWN%WI WNW OMMA p N MOW SVIIE L leOFICROW IN COWUANW OW
WON III FLOC WOO
ALAI DO 1I AImCI10 LRt0MY IO,L OMNI
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COUNTY DATE MY COMMISSION EXPIRES urea~le n1,ALIO BUNTED CO+ADOOp.Rug 1 n1.DU01 r. V .4 �. 3i 8. 071"9J�.
MO COOP a FOWL INOUATIONI IME N•FARTS MO MOWN
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NOU MOND 111.E N•mos 171 10 1K.
SRONATURE(S)(AU.PURCHASERS )MUST SIGN) DATE
IEDInMINNESOTA DEPARTMENT OF PUBLIC SAFETYDO NOT SIGN UNTIL COMPLETED
DRIVER AND VEHICLE SERVICES DIVISION,TRANSPORTATION BLDG
Mag.ate„11401.0•11.11401.0•11. 395 JOHN IRELAND BLVQ, vs 2000-1s St PAUL,MN SS155 PURCHASER'S(OWNER'S COPY)
• •... ••v.N .v .1.1.1. PM
RL . YCTTR.LG 1CPA MNVAUOAT1ONANDOFFICEUSE ONLY-
FOR CENTRAL OFFICE USE ONLY--.
w � elC
ipSTICKER NUMBER YEAR j� 0
• TITLE TITLE REG REG TM PREVIOUS PLATE NLMM I YEAR , TH YEAR DEC 1 01992
Ai REG ONLY ONLY oUNOI EXPIRATION
DATE
PURCHASER(S) DATE OF PURCNAse
DEPUTY „C:,;i:J 1 T eA�R
GECS QAIpM NATURAL OAS
OWNER(S
MUST) /41.1- /G- 9 01.. NEWUSED Tfun
I o oR rIo► — WASHINGTON COUNTY
OTHER
COMPLETE MOD.YEAR MAKE BODY/MODEL TYPE
111fOfIVI110NOTL'maiDENIPKA✓TION NIMLHa f 7 ,•co - 74/1.
/1, 44../. yD
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Information *1 - fie' , / a ►t`/s I I
OWNINES)LAST.MST.AND MIDDLE NAMES) • DRIVERS UCOEE Na
DATE OP SIM
MOT ADDRESS CRY COUNTY STATE ZP cool I
y/t --INSURANCE ta 7"! 54. ,Uo tau i 1 t sT.�,4 k.idi sit Pg /nil ` 57 ®1'A '
POLICY NUMMI
A. - • AOM!TIerIIOFe Na
"';')1/f. ..,. • /.19..,., (?.—r.- 6,416 .., 19 . VI,—
y7,,1 3
B ► IS`THIS VEHICLE SUBJECT TO SECURITY AGREEMENT(S)? YES I ) NO IF YES,SCOMPLETE SECTION BELOW. •
PAST SECURED PARTY(PRINT NAME)
• DATE OP LOAN
PURCHASER(S)
°V6410)MU
COMST SMUT ACCRUE CITYSTAT!
•
SECOND SECURED PARTY(PRINT NAME)
DATE Of ICAO FOR ADDITIONAL SECURED PARTES, . -
ATTACH COMPLETED FORM NO.PS2017.
STRUT ADDRESS CRY STATE XI CODE
C • MILES(NO TENTHS) ODOMETER STATEMENT AND ASSIGNMENT BY SELLER(SEE WARNING ON BACK OF LAST PAGE) .:
I(WE)THE OWNER(S)Of THE VEHICLE DESCRIED ABOVE,CERTIFY THE ODOMETER ON THE VEHICLE NOW READS THE MILES AS SHOWN ON THE LEFT _ ,.
SELLER(S) D AND THAT TO THE BEST Of MY(OUR)KNOWLEDGE THAT LT ERECTS THE ACTUAL MILEAGE OP THE VEHICLE DESCRIED ABOVE UNLESS OPE OF THE
MUST FOLLOWING STATEMENTS IS DECKED.I(WE)THE OWNER(S)Of DES VEHICLE CERTIFY THE VEHICLE IS HIE:OP ALL SECURRY INTERESTS WARRANT
COMPLETE TITLE.ASSIGN THE VED VEHICLE AND TAXES PATO THE PE SONS)NAMED ABOVE
AND ❑ (1)I HEREBY CERTIFY TO THE BEST OF MY KNOWLEDGE THE ODOMETER READING REFLECTS THE AMOUNT OF MLEAGE N EXCESS OF ITS MECHANICAL UNITS
SIGN 0 (2)I HEREBY CERTIFY THAT THE ODOMETER READING IS NOT THE ACTUAL MLEAGE.WARNING—ODOMETER DISCREPANCY IF BOX(1)OR(2)IS CHECKED
► DAMAGE DISCLOSURE STATEMENT. TO THE BEST OF MY KNOWLEDGE THIS VEHICLE 0 HAS 0 HAS NOT(CHECK ONE)SUSTAINED DAMAGE IN EXCESS OF 70%ACTUAL CASH VALUE.
P. POLLUTION SYSTEM DISCLOSURE STATEMENT. TO THE BEST Of MY KNOWLEDGE THE POLWTION CONTROL SYSTEM ON THIS VEHICLE NCWDNG THE RESTRICTED GASOU E PSE
0 HAS 0 HAS NOT(CHECK ONE)BEEN REMOVED.ALTERED OR RENDERED INOPERATIVE
Mars PRINTED NAMES)
DATE
(3Mla'S STREET ADDRESS CITY STATE Zr
•
D PURCHASER'S EXCISE(SALES)TAX DECLARATION t: . SALE YALR 01 REGISTRATION TAX+ $ t. >
"MS
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NO. OM TO CONVERSION FEE
COMPLETE S PET mouse PRICE Of GROSS VEHICLE WEIGHT
AND TIME Of
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•
S.LUSS TAX MD TO ANOTHER STATE TITLE/IRANSFER FEE ). gyp
NIT ECU TAX DUE t t CHAPIN I I EXCISE TAX
A TADE.IN WAS A; MAK! PLATE NUMMI
64001L YEAR E . . LATE TRANSFER PENALTY
- EXPIRES
I I • SUB-TOTAL$ t
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•
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DATE AND MdIWAYL no/WM V LL K PRATO N CdW WNiE WRN jjj
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NOUtAIIOW,NDE N.MIT$171 TO IM
SIONATUREIS)(ALL PURCHASERS )MUST SON) DATE
IrDF1 MINNESOTA DEPARTMENT OF PUSLIC SAFETY DO NOT SIGN UNTIL COMPLETED
-DINER AND VEHICLE SERVICES DIVISION,TRANSPORTATION BLDG AA 2000.Es •- -- SELLER'S COPY
,,,,,.q, ,�R,,,,,,R� 395 JOHN IRELAND BLVD.,St PAUL,MN 55155
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0 'pr."; Minnesota VEHICLE 03133490 oixop
.ij)) Vehicle Certificate ID No. ((jjijj))
Inspection INSPECTION REPORT 03133490
ii)) VER. 100 %(((i>)
AI Program
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;,�j)) CERTIFICATE AT BOTTOM NEEDED FOR LICENSE REGISTRATION RENEWAL �ii;•1)
:::. THANK YOU for cleaning up our air.Your vehicle's inspection results are printed below. If your vehicle passed the inspection, dia
6* present or mail the Inspection Certificate to the registrar when you purchase your vehicle license tabs. If your car failed, see oxi'
the back of this form for information on repair and retest requirements. Note: Repairs may be covered by the 5 year/50,000 �(�i••�))
:�� Illjl
mile warrantyprovisions of the Clean Air Act. (( ))
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:.� (This emissions test complies with the EPA short test requirements.) ��: 7)
iiij) ((iiii))
ii))) INSPECTION FACILITY INFORMATION ���!!!.!�)�
ii!)) Inspection Date/Time Station ID/Fleet ID Lane No. Inspector ID/Fleet Signature Analyzer No. 0.IIIA
i 01.11)))
• 06/02/93 10: 11 005 02 SUSANF 007834
iii)) (�.:ii�1.1
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Vii))) 0I4
iiij) VEHICLE INFORMATION ((!!!!�)
ii))) ((iiii)))
•111)) License Plate Vehicle Identification Number Year Make Type Engine Yr. Mileage 1��•��
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'`�) POLICE 1G1BL537XPW110379 1993 CHEV 4D 1993 18, 000 ..
;•iiij) ((iii))
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EXHAUST EMISSIONS READINGS �, ,)
1I.4 FAST IDLE ((iiii))
LOADED �;�s
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• INITIAL IDLE CONDITIONING FINAL IDLE /
,��)) HC(ppm) CO(%) CO2(%) HC(ppm) CO(%) CO2(%) HC(ppm) CO(%) CO2(%) (!uu)
\.w.)
1.11))) i im m inim m Minimum ((ills))
Test Maximums i ed►-r Ii , ri r. . . % r L_dr4 r r r, , . r reer, ri • r ' ,� �, \ ,'
Iii)) ((Isl0
1::::1 Initial Initial Test Readings 0120 00. 01 14. 6 0"!'))�
,1,1,1)) Retest Readings (�1111!�)
.j)� 000iss))) Initial Test Serial No. Retest Serial No. No.of fee bearing reinsp. Waiver Serial Number Insp./Reinsp.Indicator(1=Initial Test) 1 (i:0:4
:0:(0:0 03133490 0 1 ((ii))
iiij)) �((ij4
'is i)) r 1 ((i i))
EQUIPMENT INSPECTION RESULTS DIAGNOSTIC CODE INSPECTION (�' ))
iiij)) RESULT 111.
Fuel Inlet Catalytic Unvented
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,•.• Restrictor Converter Fuel Cap ',%'
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;l f)) PASS PASS PASS PASS 40.1. )
•iiij)) • ' �((i i P
IIIIi)) COMMENTS ((11��))
1111)),�, �y��,,� '""t`R^�s"fr'ry ; -^.,+-..���.. — .97-,--77.1,„,,,,,,,t.;,;0•
' ��(1111))
11111)), STATE OF MINNESOTA. INSPECTION CERTIFICATE I3-413'4,9 ► {(iliii))
1111))) ,.
Ctrficate ID No.
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ISSUEDATE 06/0 /93 TEST1WAtVERSERIAL NO: 03133490 VEHICLE LICENSE NO.: pOtI0E ((Ii i))
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, X:::'. Vim1G1 HLS37 PW 110379 VEHICLE MAKE; CHEV VEHICLE YEAR: 19 9 3 ((iiii))
sis
::: :.
If your vehicle passed, or you obtained a waiver, an extension or an INSPECTION RESULT NO.OFEE ((s ii))
BEAR NG(:Iu)) exemption, present or mail this Inspection Certificate to the registrar REINSPECTioNs (((i,111j)>
n1i} when.you purchase your vehicle license tabs. If your vehicle failed, G14S5 0 ((iii i))
(1111))} see the back of this form for information on repair and retest A
requirements. (((;;))�
11111)),,, ,'1,.-...^�.„.�—.,.-../o: : -� ^. •,(iiii:.
. COMPLETE THIS FORM BEFORE RETEST
f DIAGNOSTIC EXPLANATION
(A helpful list of possible vehicle emissions-related problems)
A.HIGH CO 1.Air cleaner dirty,or air flow restricted 4.Defective vapor cannister 7.Dirty or leaking carburetor
2.Choke stuck or out of adjustment 5. Improper idle speed 8. Improper carburetor float level
3.Defective PCV valve 6.Idle mixture too rich 9.Oxygen sensor malfunctioning
B.HIGH HC 1.Fouled or defective points,plug wires,or spark plugs 5.Mixture too lean
2. Improper timing 6.Misfire(Loaded only)
3.Vacuum leak • 7. Inoperative air pump
4. PCV or EGR valve malfunction 8.Mechanical defect
C.HIGH CO 1.Mixture too rich 4.Vacuum leak with rich mixture
AND HC 2. Ignition problems(primary or secondary) 5.Excessive fuel pump pressure
3.Carburetor malfunctioning 6.Weak cylinder(s):vacuum leak:low compression:valves
t IF YOUR VEHICLE FAILED THE EMISSIONS TEST YOU MUST: REPAIR CHECKLIST
1. Repair your vehicle by checking,adjusting,or replacing the items below that
correspond with the part your vehicle failed.
2. Complete this form and give it to the inspector before the retest.
3. Provide ALL receipts and written estimates to the waiver inspector to apply for,
a waiver.The repair cost limit is$75 for 1980 and older vehicles and$200 for HIRED REPAIRS.
1981 and newer vehicles.NOTE:The cost of replacing the fuel inlet restrictor,
catalytic converter and exhaust system components will not be applied to the SELF REPAIRS. I I I
repair cost limits for a waiver,and all pollution control devices are to be in
place and connected properly. OK Adjusted Repaired Replaced Warranty PARTS PARTS LABOR
Air Filter ✓ $ $ $
Idle Speed V
to
...1Choke V
10
E Thermostatic Air Cleaner V
PCV Valve and System V
y, Air/Fuel Mixture 4
Vacuum Hoses v
Spark Plugs V
Plug Wires
Distributor V
Dwell/Timing V
OTHER Other-Please Specify
EMISSION Other
RELATED Other
REPAIRS Other
0 k � Sg
Description of other repairs necessary fy
TOTAL TOTAL TOTAL
SPENT PARTS LABOR
FOR COST COST
PARTS
Estimate of cost for other emission-related repairs necessary to meet emissions standards:$ `, N ` x, `t
In the box to the right,total the amount actually spent for the items listed above. , ,. ,.
FORM MUST BE COMPLETED BY THE PERSON MAKING REPAIRS
Name of Person Making Repairs(print): BUSINESS FEDERAL ID NUMBER:
Business Name(If Applicable):
Address: OPTIONAL
City: State: Zip: ANALYZER NUMBER:
Telephone Number: ANALYZER CALIBRATION DATE: .
I certify that the repairs were completed solely in an attempt to bring this vehicle FINAL IDLE READINGS
into compliance.
Signature: HC ppm
CO%
Date:
CO2%
• J
PRINTED ON RECYCLED PAPER