Form Mv-300 - Request For Cancellation Of A Temporary Operating Permit

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MV-300

(Rev. 2/2011)

Request for Cancellation of a Temporary Operating Permit

Date:

For County Use Only

Original Temporary Operating Permit #:

Extension of Original Operating Permit #:

Vehicle Section

Vehicle Identification Number

Vehicle Year & Make

Type of Body and Number of Doors

Vehicle Color

Model Name or Number

No. of Cylinders

Date Purchased

Fuel Type

New or Used

Current Title#

State of Issue

Odometer reading (No tenths)

The odometer reading reflects the total actual miles the vehicle has traveled unless you check one of the following

boxes:

EXEMPT- Vehicle exempt from odometer disclosure requirements.

Exceeds the Mechanical Limits of the Odometer.

Not the Actual Mileage, Warning: Odometer Discrepancy.

Owner Section

Number of Owners _______________

Owner #1

Full Legal Name of Owner #1

Date of Birth

Driver’s License#

State/County of Issue

First,

Middle,

Last,

Suffix

(If Individual)

Business Name/Leasing Company Name

Owner #2

Full Legal Name of Owner #2

Date of Birth

Driver’s License#

State/County of Issue

First,

Middle,

Last,

Suffix

(If Individual)

Business Name/Leasing Company Name

State Address, including City, State & Zip Code

Mailing Address, if different from street address, including City, State & Zip Code

Vehicle Acquired From a Dealer, Another Person or Other Source

GA Dealer’s 12 Digit Customer#

Full Legal Name or Business Name & Address

State of Issue

REASON FOR DEALER RETURN

REASON FOR OTHER RETURN

Dealer replaced vehicle

Explanation

Vehicle wrecked or damaged by fire or flood

Explanation

Dealer purchased vehicle

Vehicle Stolen – attach police report

Dealer repossessed vehicle

Seller could not obtain title

Resold vehicle

Any person making a false affidavit or affirmation as to any matter contained in this affidavit, or forging or causing this affidavit to be forged, shall be guilty of a felony

and subject to a fine not to exceed ONE THOUSAND DOLLARS ($1,000), or imprisonment for not less than one (1) year and not more than five (5) years, or both.

(O.C.G.A. 16-10-71).

# 1 Owner’s Signature

Date:

# 2 Owner’s Signature

Date: