DATE |
RETURN |
RCVD. |
RCVD. _________ CASH $_________ DATE__________ |
DATE _________ |
CCK$________________ CCK#________________________________ |
MO$________________ MO#________________________________ |
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MISSISSIPPI MOTOR TITLE APPLICATION
Department of Wildlife, Fisheries, and Parks
Boat Registration
1505 Eastover Drive
Jackson, MS 39211-6374 601-432-2055 www.mdwfp.com
BOAT REGISTRATION # |
TITLE # |
(If related) |
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DATE OF ISSUE |
PROCESSED BY: |
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CHECK THE APPLICABLE BOXES
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1. New MS Motor Title |
$12.70 |
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4. Corrected Title Only |
$12.70 |
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2. Transfer MS Title |
$12.70 |
TOTAL AMOUNT REMITTED |
$ |
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3. Duplicate Title |
$12.70 |
If requesting a duplicate please furnish information concerning the original |
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certificate and the circumstances of its loss, theft, mutilation or destruction. |
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MAKE CHECK OR MONEY ORDER PAYABLE TO MISSISSIPPI DEPT. OF WILDLIFE, FISHERIES, AND PARKS
APPLICANT’S |
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FIRST |
MIDDLE |
DATE OF BIRTH |
SOCIAL SECURITY NUMBER |
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NAME (PRINT) |
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STREET OR POST OFFICE BOX NUMBER |
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MAILING |
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HOME TELEPHONE NUMBER |
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ADDRESS |
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CITY |
STATE |
ZIP |
COUNTY |
U.S. CITIZEN? |
WORK TELEPHONE NUMBER |
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YES |
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NO |
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E-MAIL ADDRESS |
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LAST |
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MIDDLE |
DATE OF BIRTH |
SOCIAL SECURITY NUMBER |
ACO-OWNER (IF APPLICABLE)
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DESCRIPTION OF |
MANUFACTURER |
HORSEPOWER |
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OUTBOARD MOTOR |
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MODEL YEAR |
SERIAL # |
VALUE OF MOTOR |
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MOTOR IS SUBJECT TO THE FOLLOWING LIENS
ADDRESS |
CITY, STATE, ZIP |
TELEPHONE |
NAME AND ADDRESS OF PERSON FROM WHOM |
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MOTOR WAS PURCHASED |
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DATE OF LIEN |
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$ AMOUNT OF LIEN - |
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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 irst 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 |
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CO-OWNER’S SIGNATURE |
DRIVERS LICENSE NO. |
DEALER’S SIGNATURE |
DEALER PERMIT NUMBER |
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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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FOR OFFICE USE |
DATE |
RETURN |
RCVD. |
|
RCVD. _________ CASH $_________ DATE__________ |
DATE _________ |
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|
CCK$________________ 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 www.mdwfp.com
BOAT REGISTRATION # |
TITLE # |
MI – |
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|
DATE OF ISSUE |
PROCESSED BY: |
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CHECK THE APPLICABLE BOXES
|
|
|
1. New MS Boat Title |
$12.70 |
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|
4. Corrected Title Only |
$12.70 |
|
|
|
|
|
|
|
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2. Transfer MS Title |
$12.70 |
TOTAL AMOUNT REMITTED |
$ |
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|
|
|
|
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3. Duplicate Title |
$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
APPLICANT’S |
LAST |
|
FIRST |
MIDDLE |
DATE OF BIRTH |
SOCIAL SECURITY NUMBER |
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NAME (PRINT) |
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MAILING |
STREET OR POST OFFICE BOX NUMBER |
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HOME TELEPHONE NUMBER |
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ADDRESS |
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CITY |
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STATE |
ZIP |
COUNTY |
U.S. CITIZEN? |
WORK TELEPHONE NUMBER |
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YES |
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NO |
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E-MAIL ADDRESS |
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ACO-OWNER (IF APPLICABLE)
DATE OF BIRTH SOCIAL SECURITY NUMBER
DESCRIPTION OF BOAT
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MODEL YEAR |
VALUE OF BOAT |
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HULL IDENTIFICATION NUMBER |
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MAKE |
LENGTH |
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FT |
IN |
BOAT IS SUBJECT TO THE FOLLOWING LIENS
ADDRESS |
CITY, STATE, ZIP |
TELEPHONE |
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NAME AND ADDRESS OF PERSON FROM WHOM BOAT WAS PURCHASED
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 irst 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______
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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