request for assignment and transfer of lien fee - RenewYourTag.Com

APPLICATIONMVT-21-1R 6/04TO RECORD ATRANSFER OF ALIEN WITH ANOUTSTANDINGALABAMA TITLENOT TO BE USED ONA TRANSFER OFOWNERSHIPALABAMA DEPARTMENT OF REVENUEMOTOR VEHICLE DIVISION – TITLE SECTIONP. O. BOX 327640MONTGOMERY, AL 36132-7640THIS FORM MAY BE DUPLICATED OR ADDITIONAL COPIES MAY BE OBTAINED FROM THE DEPARTMENT WEB SITE ATwww.revenue.alabama.gov/motorvehicle/mvforms/mvt21_1.pdfREQUEST FOR ASSIGNMENT AND TRANSFER OF LIENTITLE NUMBERVEHICLE INFORMATIONVEHICLE IDENTIFICATION NUMBERTRANSCODEYEARMODELCYLS NEW USED DEMO DATE OF PURCHASE (M/D/Y) NUMBERLIENS04MAKE MODEL BODY TYPECURRENT ALABAMA TITLE NO.COLOR ODOMETER READING DEPARTMENT USE ONLYOWNER INFORMATIONNAME (LAST, FIRST, MIDDLE)FELONY OFFENSE FOR FALSE ADDRESSFOR OFFICE USE ONLYMAILING ADDRESSCITY STATE ZIPNAMEALABAMA OPERATOR (LESSEE) NAME AND / OR RESIDENT ADDRESS IF DIFFERENT FROM ABOVERESIDENT ADDRESSFELONY OFFENSE FOR FALSE ADDRESSCITY STATE ZIPLIEN INFORMATIONNAME FIRST LIENHOLDERFELONY OFFENSE FOR FAILURE TO NAME LIENHOLDER WITH INTENT TO DEFRAUDMAILING ADDRESSLIEN DATE (M/D/Y)LOCATOR NO.:CITY STATE ZIPREJECT TO:NAME SECOND LIENHOLDERFELONY OFFENSE FOR FAILURE TO NAME LIENHOLDER WITH INTENT TO DEFRAUDREASONS:MAILING ADDRESSLIEN DATE (M/D/Y)EXAMINER NO.:CITY STATE ZIPENCL.:SIGN COMPLETED FORM ONLY, FELONY OFFENSE FOR FALSE STATEMENTSThe undersigned assignor and assignee confirm that the lien held by the assignor has been transferred to the assignee. Both parties hereby requestthat a new certificate of title be issued subject to the liens listed on this application.AssignorAssigneeLienholderLienholderName ______________________________________________________ Name _____________________________________________________Address ____________________________________________________Address ___________________________________________________City/State/Zip ________________________________________________City/State/Zip _______________________________________________Authorized Signature __________________________________________Authorized Signature _________________________________________Printed Name ________________________________________________Printed Name _______________________________________________Date _______________________________________________________ Date _______________________________________________________Note: Lien date for transferred lien(s) must remain the same. Also, no changes are permitted in the owner information (other than address changes).Handwritten ApplicationsWill Not Be Accepted!HANDWRITTEN APPLICATIONS WILL NOT BE ACCEPTEDTHIS FORM MAY BE DUPLICATEDFEE – $15.00Submit $15.00 Application Fee (non-refundable) incertified funds payable to Alabama Department ofRevenue. Do not send personal checks or cash.

Instructions1. Vehicle Information must be entered exactly as it appears on outstanding Alabama certificate of title.2. Owner Information must be entered exactly as it appears on outstanding Alabama certificate of title.3. Lienholder Information must be entered so that current lienholder (assignee) appears in this area. Liendate must remain the same. Do not release lien on face of title.4. Assignor and Assignee must complete their respective areas in their entirety.5. Documents should be assembled in the following order and stapled in the top left-hand corner:a. Form MVT 21-1, Request For Assignment and Transfer of Lien.b. Alabama Certificate of Title.b. Other supporting documents.6. The $15.00, non-refundable, application fee should be attached to the front of the form MVT 21-1. Donot send personal checks or cash.7. The MVT 21-1, title, supporting documents and $15.00 application fee should be mailed to the addresslisted at the top of form MVT 21-1.8. If assistance is needed, you may call Title Inquiry at (334) 242-9102.DEPARTMENT CORRECTIONPleaseCheckTCYR. MODELBTCYL.DATE OF PUR.ODOMETEROTHER:MAKEMODELPATN-U-D# LIENSLIEN DATERES. ADDRESSFOR DEPARTMENT USE ONLYABOVE INFORMATION APPLIES ONLY TOVEHICLE IDENTIFIED ON FACE OF APPLICATION