Vehicle Registration Application: Transaction Type
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Maxwell SmartVehicle Registration Application: Transaction Type
Uploaded by
Maxwell SmartVEHICLE REGISTRATION APPLICATION
STATE OF ARKANSAS
REVENUE DIVISION TRANSACTION TYPE Department of Finance & Administration
P.O. Box 1272
Little Rock, AR 72203
LICENSE NO. INV. TYPE USE CODE DECAL NO. EXPIRATION DATE VEHICLE IDENTIFICATION NUMBER
YEAR MAKE MODEL BODY CYL COLOR FUEL UNLADEN WT GROSS WT DSP AXLES PREVIOUS TITLE NO.
Gas
TITLE PUR. PUR. DATE DEALER OD OD CHECK IF APPLICABLE
CODE TYPE CODE READING DAMAGE PREV. DAMAGE LEASE PRORATE PENALTY MAIL
COMPLETE ONLY IF CONVERTING CLASS TWO (2) THROUGH EIGHT (8) TRUCK LICENSE VALIDATION PERIOD FOR DRIVE OUT OR INTRANSIT
OLD LIC. NO. OLD WT. OLD FEE IF INVOLUNTARY, SHOW AMT. OVERLOAD AND Beginning Date and Ending Date and
SUMMONS NUMBER Time Time
OVERLOAD SUMMONS
WEIGHT NUMBER
OWNER NAME
LAST FIRST REL
LAST FIRST
COMPANY
ARKANSAS ADDRESS CTY CODE TITLE MAILING ADDRESS CTY CODE
Name Name
Address Address
City AR Zip code City/State/Zip
RENEWAL MAILING ADDRESS CTY CODE REGISTRATION FEE REPLACEMENT FEE
Name
Address CREDIT TRANSFER FEE
City/State/Zip
FIRST LIENHOLDER CONTRACT DATE ADDITIONAL FEE TITLE FEE
Name
Address PRORATED FEE LIEN FEE
City/State/Zip
SECOND LIENHOLDER CONTRACT DATE SPECIAL FEE (1) PENALTY
Name
Address SPECIAL FEE (2) POSTAGE
City/State/Zip
SPECIAL FEE (3) TOTAL REG. FEES
REVENUE OFFICE CITY
OFFICE NUMBER SALES TAX RECEIPT NUMBER
COUNTY
ARKANSAS REVENUE AGENT DATE CTY CODE
SIGNATURE OF LIENHOLDER (if applicable)
SIGNATURE OF OWNERS(S)
10-381 / 12-30-2019
