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Indiana Mechanic's Lien Bill of Sale | 23104


Indiana Mechanic's Lien Bill of Sale | 23104
Indiana Mechanic
* This agency is requesting disclosure of your Social Security Number in accordance with IC 4-1-8-1; disclosure is mandatory and this record cannot be
processed without it.
INSTRUCTIONS: 1. An applicant who has purchased a vehicle in accordance with Indiana Code §9-22 must present this form to obtain a
certificate of title.
2. Complete in blue or black ink or print form. Must be completed it its entirety as incomplete forms will not be accepted.
3. A certificate or affidavit of publication from the newspaper verifying the vehicle was advertised for sale at public auction must be
included with this Bill of Sale. The vehicle may not be sold before fifteen (15) days after the date of the advertisement.
4. Proof of the mechanic’s lien notice to owner and lienholder (if applicable) must be included with this application.
SELLER INFORMATION
Person/entity who holds the mechanic’s lien
Seller’s Name (last, first, middle initial or company name) Social Security Number* or Federal Identification Number
Seller’s Legal Address (number and street) City State
ZIP Code
VEHICLE INFORMATION
Owner(s) Name (last, first, middle initial or company name)
Owner(s) Last Known Address (number and street)
City State ZIP Code
Vehicle Identification Number
Vehicle
Year
Vehicle Make Vehicle Model Vehicle
Type
Vehicle Color License Plate
Number
LIEN INFORMATION
Eligible Lien type: (required)
Labor, Materials, Storage, or Repair Work Lien (Mechanic’s lien)
Abandoned Vehicle Lien
The charges and costs against the vehicle are as follows:
Repair Work –
Labor
$
Materials
$
Storage
$
TOTAL
$
Date Vehicle Left in Seller’s Custody (month, day, year) Newspaper Name Advertisement Date (month, day, year)
The Seller, under penalty of perjury, affirms:
1. The above listed owner requested that the above described vehicle be repaired or stored and/or the vehicle has been
abandoned.
2. The vehicle was left in the seller’s custody and the owner failed or refused to claim the vehicle within thirty (30) days.
3. The owner was notified by certified mail that the vehicle described above would be sold at public auction to satisfy the
above charges.
4. The vehicle was advertised for sale at a public auction.
Signature of Seller Printed Name Date Signed (month, day, year)
PURCHASER INFORMATION
Purchaser’s Name (last, first, middle initial or company name) Social Security Number* or Federal Identification Number
Purchaser’s Legal Address (number and street) City State
ZIP Code
Date of Sale (month, day, year)
Purchase Price
$
I swear or affirm that the information I have entered on this form is correct. I understand that making a false statement may
constitute the crime of perjury.
Signature of Purchaser Printed Name Date Signed (month, day, year)
MECHANIC’S LIEN BILL OF SALE
State Form 23104 (R5 / 1-13)
INDIANA BUREAU OF MOTOR VEHICLES
BUREAU OF MOTOR VEHICLES
100 North Senate Avenue, N411
Indiana
p
olis
,
IN 46204
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Indiana Mechanic's Lien Bill of Sale | 23104