VIN TITLE NUMBER DATE ISSUED

4TARN81A5PZ112826 86310871 04/30/2005

MAKE MODEL BODY COLOR YR DATE ACQUIRED ODOMETER N/U
TOYO SIL PK GRY/ 1993 124571 U
3/30/2005

MAIL TO CL ST
* * * *
STATE FARM BR 14928801
29000 FROST RD

LIVINGSTON LA 70754

* * OWNER * *

STATE FARM MUTUAL AUTOMOBILE

INSURANCE COMPANY 1555 PROMOTORY

CIRCLE GREELEY CO
(L IE N) D A TE

The undersignedas Vehicle Commissioner

of the State of Louisiana, certifies that the
applicant named herein has been duly
registered in this office as owner of the
motor vehicle described pursuant to the
laws of the State of Louisiana, subject to
the mortgages and encumbrances, if any,
herein ser fort.

In witness whereof, I have alfixed my

signature at Baton Rouge.

FORM 2205 A 2205 37741422

DPSMV 1663 (R7/07)
 APPLICATION FOR TRANSFER BY NEW OWNER (Please print or type.)
Any change of registered owner or lienholder must be recorded with the Department of Motor Vehicles (DMV) within ten (10) days. The
title, transfer fee and in most instances, use tax and a smog certificate must be presented to DMV to record the ownership change.
3a. TRUE FULL NAME(S) OF NEW REGISTERED OWNER(S) (LAST, FIRST, MIDDLE) AS IT APPEARS ON DRIVER´S LICENSE OR I.D. CARD

3b. (LAST, FIRST, MIDDLE)

N
E
W 4. STREET ADDRESS OR P.O. BOX NUMBER

R
5. CITY STATE ZIP CODE
E
G
I 6. MAILING ADDRESS STREET OR P.O. BOX NUMBER (DO NOT COMPLETE IF SAME AS REDIDENCE ABOVE)
S
T
7. CITY STATE ZIP CODE
E
R
E 8. FOR TRAILER COACHES ONLY - ADDRESS OR LOCATION WHERE KEPT
D

O If there is a mailing address entered on this form it is a valid, existing and accurate address. I consent to receive service of process at this
W mailing address pursuant to Code of Civil Procedure Sections 415.20(b), 415.30(a) and 416.90.
N I certify (or declare) uner penalty of perjury under the laws of the State of Lousiana the foregoing is true and correct.
E 9a. DATE SIGNATURE OF NEW REGISTERED OWNER LOUSIANA DRIVER LICENSE OR ID. CARD NO. PURCHASE DATE
R
X
9a. DATE SIGNATURE OF NEW REGISTERED OWNER LOUSIANA DRIVER LICENSE OR ID. CARD NO. PURCHASE PRICE OR IF GIFT. SO STATE
X
LEASED 10. ADDREES OF NEW LESSEE IF DIFFERENT FROM LINE 4 ABOVE (WILL NOT BE PRINTED ON TITLE)
VEH.
ONLY
L11. NAME OF LIENHOLDER - FIRM OR INDIVIDUAL HOLDING SECURITY INTEREST (IF NO LIEN, WRITE “NONE”) DO NOT ENTER NAME OF REGISTERED OWNER(S) ABOVE ELECTRONIC LIENHOLDER ID
I
E ELT #
N
N
H
12. STREET ADDRESS OR P.O. BOX NUMBER
E
W O
L
D 13. CITY STATE ZIP CODE
E
R

TITLE REASSIGNMENTS BY LICENSED LOUSIANA DEALERS

FEDERAL LAW REQUIRES that you state the mileage upon transfer of ownership. Failure to complete or making a false statement may result
in fines and / or imprisonment.
The signature below releases my interest in this vehicle, acknow edges the odometer mileage recorded by the seller, and certifies to the odometer
reading entered above my signature in compliance with Fedetal law.
DEPARTAMENTOFMOTORVEHICLESDEPARTAMENTOFMOTORVEHICLESDEPARTAMENTOFMOTORVEHI
OTORVEHICLESDEPARTAMENTOFMOTORVEHICLESDEPARTAMENTOFMOTORVEHICLESDEPARTAMEN

14. Odometer now reads: , (no tenths) miles, and to tho best of my knowledge reflects the actual mileage of the vehicle unless
OTORVEHICLESDEPARTAMENTOFMOTORVEHICLESDEPARTAMENTOFMOTORVEHICLESDEPARTAMEN

D R / S NUMBER
DEPARTAMENTOFMOTORVEHICLESDEPARTAMENTOFMOTORVEHICLESDEPARTAMENTOFMOTORVEHI

one of the following statements is checkec: WARNING- Mileage is not the actual mileage. exceeds the odometer mechanical limits.
E I certify (or declare) under penalty of perjury under the laws of the State of Lousiana that the foregoing is true and correct.
A
DATE SIGNATURE OF AUTHORIZED AGENT PRINTED NAME OF AGENT DEALER NAME DEALER NUMBER
L
E X
R DATE BUYER´S SIGNATURE, ACKNOWLEDGES ODOMETER READING PRINTED NAME OF BUYER OR AGENT SALES PERSON´S NO.

T SOLD THROUGH
X DEALER NUMBER
DATE OF AUCTION AUCTION NAME
R AUCTION IF APPLICABLE
A DEPARTAMENTOFMOTORVEHICLESDEPARTAMENTOFMOTORVEHICLESDEPARTAMENTOFMOTORVEHI

N 15. Odometer now reads: (no tenths) miles, and to tho best of my knowledge reflects the actual mileage of the vehicle unless
OTORVEHICLESDEPARTAMENTOFMOTORVEHICLESDEPARTAMENTOFMOTORVEHICLESDEPARTAMEN
OTORVEHICLESDEPARTAMENTOFMOTORVEHICLESDEPARTAMENTOFMOTORVEHICLESDEPARTAMEN

,
DEPARTAMENTOFMOTORVEHICLESDEPARTAMENTOFMOTORVEHICLESDEPARTAMENTOFMOTORVEHI
R / S NUMBER
S one of the following statements is checkec: WARNING- Mileage is not the actual mileage. exceeds the odometer mechanical limits.
A I certify (or declare) under penalty of perjury under the laws of the State of Lousiana that the foregoing is true and correct.
C DATE SIGNATURE OF AUTHORIZED AGENT PRINTED NAME OF AGENT DEALER NAME DEALER NUMBER
T
I DATE
X
BUYER´S SIGNATURE, ACKNOWLEDGES ODOMETER READING PRINTED NAME OF BUYER OR AGENT SALES PERSON´S NO.
O
N X
S 16. Odometer now reads: DEPARTAMENTOFMOTORVEHICLESDEPARTAMENTOFMOTORVEHICLESDEPARTAMENTOFMOTORVEHI
OTORVEHICLESDEPARTAMENTOFMOTORVEHICLESDEPARTAMENTOFMOTORVEHICLESDEPARTAMEN

(no tenths) miles, and to tho best of my knowledge reflects the actual mileage of the vehicle unless
,
OTORVEHICLESDEPARTAMENTOFMOTORVEHICLESDEPARTAMENTOFMOTORVEHICLESDEPARTAMEN

R / S NUMBER
DEPARTAMENTOFMOTORVEHICLESDEPARTAMENTOFMOTORVEHICLESDEPARTAMENTOFMOTORVEHI

one of the following statements is checkec: WARNING- Mileage is not the actual mileage. exceeds the odometer mechanical limits.
O I certify (or declare) under penalty of perjury under the laws of the State of Lousiana that the foregoing is true and correct.
N
DATE SIGNATURE OF AUTHORIZED AGENT PRINTED NAME OF AGENT DEALER NAME DEALER NUMBER
L
Y X
DATE BUYER´S SIGNATURE, ACKNOWLEDGES ODOMETER READING PRINTED NAME OF BUYER OR AGENT SALES PERSON´S NO.