Dealer Application for Certificate of Mobile Home Ownership Date* MM slash DD slash YYYY Dealer*Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code County*Telephone Number*(Include Area Code)License Number*Sales Tax License Number*Trade-in?* Yes No Manufacturer Identification Number of Trade-inThis information about the mobile home sold is for statistical purposes only: New Single Section Previously Owned Single with expando Brokered Multi-section Manufacturer/Brand NameManufacturer's Identification NumberYear of ManufacturePurchaser's NameAddress Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Purchase/Stock Number [Rule 402(1)(c)]Full Rights to Survivor? Yes No Filing Date 1st S.L.Filing Date 2nd S.L.1st Secured PartyAddress Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code 2nd Secured PartyAddress Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Price of Mobile Home(Including federal tax, freight and accessories)Other Taxable Charges(service fee, etc.)Total Taxable PriceSales TaxCertificate of Mobile Home Ownership FeeLabor or Other Non-Taxable ChargesTotal Delivered Price1. DO NOT sign a blank form. 2. If your Certificate of Mobile Home ownership is NOT received within 60 days, contact a Secretary of State Office. 3. The Dealer must provide the purchaser a copy of this application after the sales tax and Certificate of Mobile Home Ownership fees have been paid. I certify I sold this manufactured home to the purchaser listed on this form and I further certify at time of delivery the mobile homes is subject to the security interest named.1. DO NOT sign a blank form. 2. If your Certificate of Mobile Home ownership is NOT received within 60 days, contact a Secretary of State Office. 3. The Dealer must provide the purchaser a copy of this application after the sales tax and Certificate of Mobile Home Ownership fees have been paid. I certify I sold this manufactured home to the purchaser listed on this form and I further certify at time of delivery the mobile homes is subject to the security interest named. I agree I do not agree Dealer's Signature and TitleI (we), the purchaser(s) of this mobile home, certify it is equipped with 1 fire extinguisher and smoke detector as required by 1974 PA 133, MCL125.711 et seq. of the Michigan Complied Laws.I (we), the purchaser(s) of this mobile home, certify it is equipped with 1 fire extinguisher and smoke detector as required by 1974 PA 133, MCL125.711 et seq. of the Michigan Complied Laws. I,(we), agree I,(we), do not agree Purchaser's Signature (DO NOT SIGN BLANK FORM)Purchaser's Signature (DO NOT SIGN BLANK FORM)Purchaser's Signature (DO NOT SIGN BLANK FORM)Co-Signer's signature, if applicable (DO NO SIGN BLANK FORM)Failure to file for a Certificate of Mobile Home Ownership within 30 days of the sale will result in a late fee of $15.00 Authority Granted under 1987 PA 96 to receive a Certificate of Mobile Home Ownership. LARA is an equal opportunity employer/program. Auxiliary aids, services and other reasonable accommodations are available upon request to individuals with disabilities. BCC-944 (rev. 9/14)PhoneThis field is for validation purposes and should be left unchanged.
