Form Tc 96-167 - Aaffidavit For Replacement Or Non-Exchange - Kentucky Department Of Vehicle Regulation

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TC 96‐167 
   Kentucky Transportation Cabinet 
Rev: 10/2014 
Department of Vehicle Regulation 
   Division of Motor Vehicle Licensing 
AFFIDAVIT FOR REPLACEMENT OR NON‐EXCHANGE 
KRS 186A.990  states:  Any person knowingly giving false information in connection with an application or title shall be guilty of forgery in the second degree.
When making application for a duplicate title on a vehicle, please use TC 96‐182, Application for Title or Registration. 
Affidavit for Replacement County: 
           
I CERTIFY THAT MY 
 Certificate of Registration     IS 
 Lost 
 Registration Plate 
 County Change 
 Decal 
 Stolen  
 
 Destroyed    
 
 Rusted   
 Other                   
 
Describe 
I hereby request a replacement for Registration Certificate, Registration Plate, or Decal # 
           
           
           
             
           
Owner(s) Name 
ID (SSN or DL#) 
  Owner(s) Name 
ID (SSN or DL#) 
           
             
     
           
Street Address 
   City 
State 
Zip 
 
 
 
Signature 
Date 
 
Signature 
Date 
Affidavit for Non‐Exchange County: 
           
Title or Registration CTL #  
           
 Repo 
 Plate Replacement 
I CERTIFY BASED ON THE 
OR REGISTRATION ACTION 
 Junked Vehicle 
 Vehicle Type Conversion 
FOLLOWING TITLE ACTION: 
 Salvage Title 
 Registration Conversion 
 Title Only Transfer 
 Registration Cancel 
that the License Plate assigned to the motor vehicle or owner herein: 
 
VIN 
           
Plate 
           
and Decal  
           
described and currently registered in the Commonwealth of Kentucky does not 
accompany the associated documents related to the aforementioned action because of the following non‐exchange 
reason: 
 Lost 
 Special Plate  
           
 
 Stolen 
 Out of State 
 
 
 Destroyed 
 Other 
           
 
 
Describe 
           
           
             
           
Name of Company or Dealership 
ID (SSN or DL#) 
  Owner(s) Name 
ID (SSN or DL#) 
             
           
Lending Institution 
  Street Address 
             
           
     
           
Street Address 
  City 
State
Zip 
   
           
     
           
 
City 
State  Zip 
 
 
 
 
  Owner’s Signature 
Signature of Authorized Representative 
Date 
Notary for Replacement or Non‐Exchange 
 
 
Subscribed and attested before me on this date
My Commission Expires
 
 
 
  MM          DD          YY
  MM          DD          YY 
 
________________________________________________________ 
Attesting Official or Notary Signature and Title
 

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