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MY.827 (373) ~ _ Be ” . PAGE 4 FILL-OUT ALL SECTIONS BELOW WHICH APPLY TO YOU —— A. TO CERTIFY THAT YOUR VEHICLE WAS INSPECTED FOR A DUPLICATE OR ORIGINAL REGISTRATION I certify the! the vehicle was inspected on : Cartiticate Mo. a Station tHe, A.62- O, —- » (Month)! (Fear). nn . B. FOR REPLACEMENT OF REGISTRATION ITEMS * Guanae og ; . +f you nay tost any registration items or if they heave been mutila onan Shan FS rot adress wun 10 says Ere now 1 © . aI a Registration Renewal : mee registration ; Certiticate Stub - : C. TO AMEND YOUR REGISTRATION + Gneck deapesttion ang fil ik GAS ede te VON Fae « name change print your former name delow. Give thie stud ‘0 the nee wlorm ‘ exactly se it je on your present registration. . For ¢ chenge other than name, Date of Cmpceition give the reason for the change: ©. FOR SPECIAL REGISTRATIONS ONLY _-~ 8. Have you been convicted for speeding. reckless or any violstion requiring the revocetion of your driver's past 18 months? O Yes No i O tronaterres DD arta, Secsen 429 of re Veticte & Trafic Law complied win i C Regieserad Sesion, Returned te Sheet cl. ‘ Citicton rig. tite arid ineerent sate O Write poresrenty opened tree te Bate ! OR BOAT OR UTILITY TRAILER ONLY ; i cartity that this trailer js not used for business or com 4 . a j private passenger vehicie registered in Now York State in my Smet ts ae oo . | . Coma vores on . Year_____ exe _______ ists No. __ & ¢ merbw of note or attic, of By cones 7 tome On bare Gonced s.! F. CHECK ANY BOXES IN THIS SECTION WHICH APPLY] ganas os secur fg Q tt 1s used only e¢ an agricultural teuch. (form MY.259F | mutt de attached.) i ip used only in the transportation of household goods under 1.C.C., or Dept. of Transportation Authority. CT} tt is under Dept. of Transportation Authority. ("weet seceety 08 on eemttonce. Cnech #: ((} fee is charaed tor corvying Passengers. Permit Number C) tt is under Interstate Commerce Commission Authority. . [ss 84 20 invald cnach or tenaree. 1.C.C. Permit Number oO It be under government ownerchip. ; G. OWNER OF VEHICLE IF NOT REGISTRANT ; Lest First hast Middtle taitial pase |“o- or ! Address chy State a? Cus ! No. and Street tH. ADDITIONAL LIENHOLDERS List any lienhoiders other than these on the front of this form. =. Laem Date dvd Lienholder = Name _ Matling Sime Cots Address [ Fal ath LienhoWer =» Name . _ a ers - Mailing City State . ZIP Cogs Address 1. E CERTIFY THAT: } : 1, The information given on this application + true. ©. $f required, Financial Security 2 currently an etlect, 2. There ere no untatished judgments against me as a 7. if @ farm vehicle registration, the veticie aif act be mantel Petult of @ motor vehicie on @ public highway except on the eeutes indicted on 3. The registration ts not currently under suspemion Mv Te0F. Of revocation, S of a pessenger registration. petiengers oF net Be carving t 4. The vehicle 14 fully equipped in sccortarice with tte “*. °°” fr Mire. requirements of the Vehicle and Traffic Lew. 9. Hf plates in a tories reserved Ser 2 eperiut grea, &, There are no ovistanding orders against me under the | Pave only one sat of these pistes. Financial Security Act. * 22. . ‘ SIGN _W¥?- fs I . z HERE Sigd name in th. NOt wndrvidual Owner, grve Uitte. EEE DEALER CERTIFICATION . + certify that the Henholders listed on this form are the only recorded lienhoidars for this vehicle i re Re Anown to me. Sgnsture of Dester Dt mere RIJS74 4072200152 . t£e6<403 wee . 2 N 4 “7-15200 192052 Fr] Fe