Application for Duplicate and Replacement License Plate or Decal
Requesting the replacement of a lost/destroyed license plate by an affiant requires the execution of the following affidavit. This affidavit is used for making an under-oath statement that their license plates are indeed lost/stolen.
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APPLICATION FOR DUPLICATE/REPLACEMENT
LICENSE PLATE OR DECAL
(T.C.A. 55 -4-103(b)(4)(g))
Check the appropriate box:
Duplicate Plate ____________________________
(Plate Format) Class Code/Issue Year
Replacement Plate ________ __________________ ____________________________
License Plate Number Class Code/Issu e Year
Replacement Decal __________________________
Decal Number
_________________________________ _____________________ ____________________
VIN Make Yr. Model
I certify that the above listed license plate or decal, issued for the vehicle herein described, has been
los t , stolen or mutilated . I further certify that I have reported the loss or theft of this plate or
decal to the following local Law Enforcement Agency.
________________________________________ ______________________________________
Law Enforcement Agency Officer’s Name
Note: A duplicate plate will not be issued until the holder affirms that proper law enforcement
notification has be en made.
Under penalties of perjury, I hereby certify this information is correct to the best of my knowledge.
________________________________________ ________________________________
Owner/ Certifier Date
Sworn to and subscribed before me this the _____________________ day of _______________________,
20_________.
__________________________________________________
Notar y Public
My commission expires: _______________________________________________________________
RV -F1315301 (Rev. 7 -12) RDA 692
Tennessee Department of Revenue
Vehicle Services Division
44 Vantage Way, Suite 160
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