Billing

A. Vehicle Information

Vehicle Identification No (VIN)(Required)

Year(Required)

Make(Required)

Model(Required)

Odometer Reading(Required)

Date of Sale/Transfer(Required)

Purchase Price(Required)

B. Seller(s) / Transferor(s) Information

Seller(s)’/Transferor(s)’ Full Legal Name(s)

First(Required)

Last(Required)

Mailing Address

Street No.(Required)

Street Name(Required)

Apt./Suite No.

City(Required)

State(Required)

Zip Code(Required)

County(Required)

C. Purchaser(s) / Transferee(s) Information

Purchaser(s)’/Transferee(s)’ Full Legal Name(s)

First(Required)

Last(Required)

Mailing Address

Street No.(Required)

Street Name(Required)

Apt./Suite No.

City(Required)

State(Required)

Zip Code(Required)

County(Required)

D. Certiication

I/we, the seller(s)/transferor(s) named in Section B, sold or transferred the vehicle described herein to the buyer(s)/transferee(s) named in Section C. I/we hereby certify that to the best of my/our knowledge the odometer reading reflects the total actual mileage of the vehicle unless otherwise indicated. I/we further state that there are no liens, security interests, or encumbrances on this vehicle except as listed in Section D.

Seller(s)’/Transferor(s)’ Signature(s)

Primary Seller(Required)

Date(Required)
MM slash DD slash YYYY

Secondary Seller

Date(Required)
MM slash DD slash YYYY

Buyer(s)’/Transferee(s)’ Signature(s)

Primary Buyer(Required)

Date(Required)
MM slash DD slash YYYY