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APPLICATION FOR CERTIFICATE OF TITLE FOR A VEHICLE State Form 205 (R11 / 3-20) INDIANA BUREAU OF MOTOR VEHICLES *This agency is requesting disclosure of your Social Security Number / Federal Identification Number in accordance with IC 4-1-8-1; disclosure is mandatory, and this record cannot be processed without it. To be completed by a police officer, BMV official, or BMV certified dealer signee for out-of-state titles. I hereby certify that I personally examined the following vehicle and find the identification number to be as follows. I swear or affirm that I am authorized to perform this transaction, and I agree to indemnify and hold harmless the Indiana BMV from any and all liability arising from this transaction. I swear or affirm that the information that I have entered on this form is correct. I understand that making a false statement on this form may constitute the crime of perjury. Applicant Signature: Printed Name: Applicant Signature: Printed Name: Date (mm/dd/yyyy): Vehicle Identification Number Year Make Model Type Date (mm/dd/yyyy) Inspector’s Printed Name and Title City Inspector’s Signature Badge, Branch, or Dealer Plate Number Transaction Number Branch Number Invoice Number BMV Use Only Social Security Number / Federal Identification Number * Name of Applicant BMV Use Only Residence Address (number and street) City State ZIP Code Vehicle Identification Number Vehicle Year Vehicle Make Vehicle Model Vehicle Type Odometer Former Title Number Purchase Date (mm/dd/yy) Lien (Y/N) Speed (Y/N) Dealer Number BMV Use Only Electronic Lien and Title (ELT) identification number Holder of First Lien, Mortgage, or Other Encumbrance / Special Mailing Address Mailing Address (number and street) City State ZIP Code BMV Use Only Electronic Lien and Title (ELT) identification number Holder of Second Lien, Mortgage, or Other Encumbrance Mailing Address (number and street) City State ZIP Code BMV Use Only License Number License Year Forms Used Gross Retail and Use Tax Affidavit – I/We hereby certify that sales or use tax on this vehicle was paid as indicated below. Selling Price $ Less Trade-In / Discount $ Amount Subject to Tax $ Amount of Tax $ Dealer Branch Exempt Exemption Code Reset Form