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APPLICATION FOR CORRECTED TITLE/ODOMETER <br /> �t �f^�� <br /> �` y:�a Minnesota Department of Public Safety, Dnver and Vehicle Services Division <br /> '�`c R-k 445 Minnesota Street, Suite 165, St. Paul, MN 55101-5165 <br /> � ; Phone: (651)297-2126 TTY: (651) 282-6555 Intemet: www.dps.state.mn.usldvs <br /> ��\'°="""��y�� PLEASE READ INSTRUCTIONS BEFORE COMPLETING <br /> This form is used when information is printed incorrectly on a certificate of tiUe or when alteration or erasure has occurred on the title. <br /> 1. Complete the vehicle identification information as it appears on the current title. <br /> 2. Attach this form,when compieted,to the current certificate of title. <br /> 3. For a name change request,the new Driver's License number should be indicated next to owner(s)signature. If the Driver's <br /> License has not been changed, proof of the name change(certified copy)is required. <br /> 4 All sellers and buyers must sign for corrections on aitered safe dates,and for correction on aiometer,damage,and pollution <br /> disclosure statements. <br /> Assistance in completing this form and the appropriate fees may be obtained by contacting a deputy registrar or the Driver and Vehicle <br /> Services Divfsion. � <br /> i . A.F,Lc. �4�,�1c,1 <br /> Vt'tiiCL�i�r�fT'��l�.A ivtr IvU�4[iER ' e::r .r.... . <br /> L i / ri�1- / ��/ C, ;> ,-' <br /> 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 l�/) <br /> � 1-�tle Number Plate Number <br /> FOR CORRECTED ODOMETER/DISCLOSURE STATEMENTS: <br /> OOOME7ER DISCLOSURE STATE6AENT,I(W�CERTIFY 7HAT THE ODOMETER DANAGE�ISCLOSURE STATEMEHTS.TO THE BEST OF MY KNCWLEDGE THIS VEHICIE <br /> NOW RFADS (NO TENTHS)MILES AND � � ❑ �-�qS NOT(CHECK ONE�SUSTAINED�AMAGE IN EXCESS OF 70'�ACTUAL CASH VALUF <br /> �f0 THE BcST OF MY KNOWLEDGE THE ODOMETER MILEAGE IS: <br /> ❑ ACTUAL MILEAGE F'OLLUTION SYSTEM�ISCLOSURE STATEME TO THE BEST OF MY KNCWLEDGE THE POLUJiICiN <br /> CONTROL SYSTEM ON THIS VEHICIE INC ING ICTE ASOLINE PIPE. <br /> ❑ EXCFEDS MECHANICAL LIMITS OF ODOMETER � HqS ❑ NAS NOT(C CK ONE)BEEN REMOVED.ALTEREO OR fjEND RED iNOPERATN[ <br /> ❑ NGi ACTUAL MILE/�GE-WARNING ODOMETER DISCREPANCY � ,�✓ A �,V <br /> x <br /> �'� P��'� c <br /> Al1 SELLER'S SIGNATURE(S) �� ,D ,` . <br /> ,� �ctil�b ,�,� <br /> x <br /> ALL BUYER'S/APPLICANT'S SICN/�TURE(S) '� 8�1 <br /> FOR ALL OTHER CORRECTIONS: <br /> � The hcorrect � . (�, �' <_. ������ ,t� _ /_.� '`* �. <br /> �r� ������. <br /> � rr�u� / % `r�, <br /> cti,...i,+n,.,.,�. <br /> v� Explanation ` % , _ } " �- �, �. , � - ��" _ < , - <br /> i r..,.. c.' �'��t <br /> Sellefs Signature(s) � Dnvers License Number(s) <br /> l.:/ X <br /> BuyerslApplicanYs SiSnature(s) Drivers License Number(s) <br /> �f X <br /> NOTICE <br /> Ali data collected on a motor vehicle application are required by law. These data are used to identify your motor vehide. <br /> Faiture [o provide required data may result in denial of the transfer of ownership, registration of this vehicle, or other <br /> requested action. Except for ceRain uses permitted by federal and state laws, personal information contained in your <br /> application may not be disclosed to anyone without your express consent. <br /> PS2025-15 <br />