
FOR OFFICE USE
DATE
RCVD. _________ CASH $_________
RETURN
DATE__________
RCVD.
DATE _________
CCK$________________ CCK#________________________________ MO$________________ MO#________________________________
MISSISSIPPI BOAT TITLE APPLICATION
Department of Wildlife, Fisheries, and Parks
Boat Registration
1505 Eastover Drive
Jackson, MS 39211-6374
601-432-2055
www.mdwfp.com
BOAT REGISTRATION #
MI –
TITLE #
DATE OF ISSUE PROCESSED BY:
CHECK THE APPLICABLE BOXES
1. New MS Boat Title
$12.70
4. Corrected Title Only
$12.70
2. Transfer MS Title
$12.70 TOTAL AMOUNT REMITTED $
3. Duplicate Title
$12.70
If requesting a duplicate please furnish information concerning the original
certificate and the circumstances of its loss, theft, mutilation or destruction.
MAKE CHECK OR MONEY ORDER PAYABLE TO MISSISSIPPI DEPT. OF WILDLIFE, FISHERIES, AND PARKS
APPLICANT’S
NAME (PRINT)
LAST FIRST MIDDLE
DATE OF BIRTH SOCIAL SECURITY NUMBER
MAILING
ADDRESS
STREET OR POST OFFICE BOX NUMBER
HOME TELEPHONE NUMBER
CITY
STAT E ZIP COUNTY U.S. CITIZEN?
YES NO
WORK TELEPHONE NUMBER
EMAIL ADDRESS
A CO-OWNER
(IF APPLICABLE)
LAST FIRST MIDDLE
DATE OF BIRTH SOCIAL SECURITY NUMBER
DESCRIPTION OF BOAT
HULL IDENTIFICATION NUMBER
MODEL YEAR VALUE OF BOAT
MAKE LENGTH
FT IN
BOAT IS SUBJECT TO THE FOLLOWING LIENS
FIRST LIEN BOAT ADDRESS CITY, STATE, ZIP TELEPHONE NAME AND ADDRESS OF PERSON FROM WHOM
BOAT WAS PURCHASED
DATE OF LIEN $ AMOUNT OF LIEN
I CERTIFY THAT I OWN THE ABOVE BOAT AND UNDERSTAND AND AGREE THAT AN EXAMINATION MAY BE MADE OF THE BOAT BY THE
STATE OF MISSISSIPPI, DEPARTMENT OF WILDLIFE, FISHERIES AND PARKS.
STATE OF ______________________________________ Appeared before me _______________________________________________, who first being duly SWORN
says that of his or her own personal knowledge all the information given and STATEMENTS made on the application are true and correct and that the watercraft described is
subject to no liens or encumbrances except as noted on the application.
THIS THE ______________________________________________ DAY OF ___________________________________________________, 20______
APPLICANT’S SIGNATURE DRIVERS LICENSE NO.
NOTARY’S SIGNATURE MY COMMISSION EXPIRES
CO-OWNER’S SIGNATURE DRIVERS LICENSE NO.
DEALER’S SIGNATURE DEALER PERMIT NUMBER
Mississippi Code Section 97-7-10 states (in Part).... “Whoever makes or uses any false, fictitious, or fraudulent statement or entry, shall, upon conviction be punished by a fine of
not more than $10,000.00 or by imprisonment for not more than 5 years, or by both such fine and imprisonment.”
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REV. 12/09