KANSAS

DEPARTMENT OF REVENUE DIVISION OF VEHICLES www.ksrevenue.org

KANSAS RESIDENT/BUSINESS OUT OF STATE VIN VERIFICATION

Reverse side (page 2) has Instructions and Additional Information Part I – OWNER DECLARATION (To be completed by vehicle owner) I, the under signed, certify that I have a title issued by another state or country for vehicle described below which has been assigned to me by the owner of the vehicle and the vehicle is located outside of Kansas due to the qualifying reason checked below: (Check one and explain) Kansas resident on active military duty stationed out-of-state, Kansas resident attending an out-of-state college, university or school, Application for Kansas apportioned registration, Kansas resident or business temporarily* out of Kansas. Date the vehicle will be returned to Kansas: * Reason: Explanation: I further certify that the foregoing is true and correct. I understand that by submitting this form with an application for Kansas title and registration I agree to any and all requirements indicated on this form and any additional requirements as determined by the Kansas Division of Vehicles and/or the Kansas Highway Patrol. All decisions by the Division and/or the Patrol are final.
Owner’s printed name Owner’s signature Date

Owner’s Out of State Address

City

State

ZIP

Owner’s Kansas Address

City

State

ZIP

Part II – VIN VERIFICATION (Must be completed by Law Enforcement Officer)
Vehicle Identification Number

Must be Typed or Completed in Ink.

Year Title Issued by the State of Title branded (labeled)? No

Make Title Number Yes, as: Salvage

Model

Body Style Odometer Reading Other: No VIN on documents

Color (No Tenths)

Rebuilt/Restored Salvage Disagrees with VIN

SUPPORTING DOCUMENTS: (Check one)

Agrees with VIN

See Remarks

Remarks:

I certify that I am a law enforcement officer and I have physically examined the vehicle and title described herein and the information