Affidavit for Inspection of an Antique Vehicle - BIPAC

APPLICATION FOR SPECIAL IDENTIFICATION NUMBERFOR MOTOR VEHICLE, HOUSE CAR AND OTHERSELF-ASSEMBLED MOTOR VEHICLES.State Form 12907 (R3 / 6-00) / Form T-1AApproved by State Board of Accounts, 2000STATE OF INDIANABUREAU OF MOTOR VEHICLESINDIANAPOLIS, IN 46204The undersigned hereby makes application for permission to affix a specialidentification number on the vehicle described herein in an easily accessibleplace on the vehicle.Branch numberInvoice numberThis application will not be considered unless every blank is properly filled,and the same signed under penalty of perjury and accompanied by the statutoryfee.MVIN numberFeeINDPLEASE PRINT OR TYPEName of applicant (first, middle, last)Date (month, day, year)Address (number and street, city, state, ZIP code)CountyType of vehicle (i.e: semi-trailer, house car, privately assembled motor vehicle)Style of bodyMake Model Year License numberDate of purchase Title number Identification numberFrom whom purchased (first, middle, last)Address (number and street, city, state, ZIP code)Give a description of defacement or mutilation or other reasons why no serial or identification number appears on the vehicle described above.(i.e.: numbers chiseled off, privately assembled, plate removed, idented numbers filed in)I, do swear or affirm that the information I have entered on this form is correct. I understand that making a false statement on this form may constitutethe crime of perjury.Signature of applicant (must be signed in ink) Printed name of applicant Date