ACTION

REQUIRED:
Please review and keep
with your insurance
Date: April 07, 2022 documents.

Dear Nathan,

Please see the enclosed form(s).

Attached is your RMV form. This form is required as proof of

insurance when registering your vehicle in Massachusetts. Please print
and sign this form. *
Note, the Registry of Motor Vehicles may reject this printed form for
the following reasons:
The form is not printed on 8 ½ X 11 white paper
The form is printed on color paper
The form is printed on card stock
The form is not signed in the appropriate places by the
registered owner(s) or fields are left blank
The form is not legible due to ink smears or low toner marks
The form is not the required two-page document
*If printing in Adobe, select the print option. Under Page Handling, set
Page Scaling to "None"

Thank you for being a loyal Liberty Mutual customer.

Sincerely,
Liberty Mutual
 Registration and Title Application

I Want To: Change plate on existing vehicle with no

A. Service Type amendments*
Register and title a vehicle
Renew a registration*
Select the transaction to be performed. Transfer plate to a new vehicle*
Provide the plate number below if applicable. Amend a registration*
Reinstate a registration*
Select the information to be amended.
Plate Type Plate Number Apply for a salvage title Enter new information in the section indicated.
Apply for a title only Registration Type (B 3.) Address (D, E or F)
Transactions/Amendments in bold require an Apply for a registration only Color (B 4.) Lessee (E)
insurance stamp. Fuel Type (B 8.) Garaging Address (G)
Transfer a plate between two vehicles*
Italicized transactions may require an Total Gross Weight Insurance (K)
Register previously titled vehicle (B 12.)
insurance stamp. Other:
Title previously registered vehicle* Name (D or F)
Transactions with * require plate type and
number above. Transfer vehicle to surviving spouse* VIN (B 1.) For vehicles with no MA Title
B1. Vehicle Identification Number (VIN) B2. Body Style
B. Vehicle Information 2T1BR38E94C177593 SEDAN
B3. Registration Type: X Passenger Commercial Bus Livery Camper B4. Color(s): Black White Brown Blue Yellow X Gray
Trailer Taxi Motorcycle Semi-Trailer Other: Purple Green Orange Red Silver Gold
B5. Year Make Model Model# Trim
2004 TOYO COROLLA

B6. Transmission Type: Automatic B7. Number of: Cylinders / Passengers / Doors B8. Fuel Type: Gas Electric Propane B9. Odometer (Miles)
Other: Manual 4 / / 4 Diesel Hybrid Other: 132,958

B10. Bus: Regular DPU School Bus School Pupil B11. If carrying passengers for hire, B12. Total Gross Weight (Laden)
School Pupil/Taxi School Pupil/Livery enter max seating capacity Cannot exceed GVWR

C1. Vehicle Condition New Used C2. Previous Title Issue Date (MM/DD/YYYY)
C. Title Information
C3. Previous Title Number Previous Title State Previous Title Country

C4. Title Type: X Clear Salvage Reconstructed C5. Primary Salvage Title Brand: C6. Secondary Salvage Brand(s): Vandalism Flood
Theft Prior Owner Retained Owner Retained Repairable Parts Only Theft Fire Salt Collision Other
D1. Select Owner(s) Identification Requirement being provided for registration purposes MA License/ID
D. Owner 1 Information
Out-of-State License Out-of-Country License Social Security Number Lawful Presence
D2. 1st Owner's Name (Last, First, Middle) D3. Date of Birth (MM/DD/YYYY) D4. License#/ ID#/ SSN
BRODIEN,NATHAN,J
D5. Residential Address Apt. # City State Zip Code D6. State/Country of License/ID
96 ILLINOIS ST APT 3 WORCESTER MA 01603-2663
D7. Mailing Address Same as Residential Apt. # City State Zip Code D8. Exp. Date of License/ ID/ Lawful Presence
96 Illinois St Apt 3 Worcester MA 01603-2663
D9. Email Cell Home Work Phone#

Owner 2 Information D10. Select Owner(s) Identification Requirement being provided for registration purposes MA License/ID
Out-of-State License Out-of-Country License Social Security Number Lawful Presence
D11. 2nd Owner's Name (Last, First, Middle) D12. Date of Birth (MM/DD/YYYY) D13. License#/ ID#/ SSN

D14. Residential Address Apt. # City State Zip Code D15. State/Country of License/ID

D16. Mailing Address Same as Residential Apt. # City State Zip Code D17. Exp. Date of License/ ID/ Lawful Presence

D18. Email Cell Home Work Phone#

E. Lessee Information / In Custody of

E1. 1st License #/ ID #/ SSN/ FID E2. 1st Lessee or Corp/Co/Organizations Name E3. 1st Lessee Address

E4. 2nd License #/ ID #/ SSN/ FID E5. 2nd Lessee or Corp/Co/Organizations Name E6. 2nd Lessee Address

TTLREG100_1119
 F. Business Owner Information F1. Email Cell Home Work Phone#

F2. EIN/FID F3. Corp/Co/Organization/Lessor Name F4. USDOT# F5. TIN#

F6. DBA Dealer - Farmer - OC - Repair - and Transporter use only F7. SSN if Sole Proprietor

F8. Physical Address Apt. # City State Zip Code

F9. Mailing Address Same as Physical Address Apt. # City State Zip Code

G. Garaging Address Address where vehicle is principally garaged.

G1. Address Apt. # City State Zip Code
96 ILLINOIS ST APT 3 WORCESTER MA 01603-2663

H. Lienholder Information The bank, financial institution, or private party that financed your vehicle loan.
1st Lien Code Name Address

2nd Lien Code Name Address

3rd Lien Code Name Address

Numbers I1 or I2 must be completed by a licensed dealer. Number I3 must be completed for all
I. Sales or Use Tax Schedule casual/private sales. Number I4 is completed for sales tax exemptions by the RMV.

I1. Sale by Licensed Motor Dealer Dealer EIN/FID #: I2. Sale By Auction

Authorized Dealer's Signature: Sale Price including Buyer's Premium:

MSRP: Total Sales Price: I3. Sale By Other Than Motor Vehicle Dealer or Auction House
(Casual Sale)
Less Manufacturers Excise: Gross Sale Price (Proof Required):
Trade-In 1 VIN: Less Trade-In Allowance: MA Sales/Use Tax:
Year: Make: Model: Out of State Sales Tax Previously Paid:
Trade-In 2 VIN: Less Trade-In Allowance: State that Sales Tax was Paid to:
Year: Make: Model: I4. Claim Exemption Code
Taxable Sales Price: MA Sales Tax Paid: Form Attached (If Required)

J1. Purchase Date: J2. Is this vehicle being converted from another state with the same owner?
J. Purchase Information 06/10/2003 If Yes, answer questions J3-J5 below Yes No
J3. MA Resident at J4. Was Mass Sales J5. Proof of Tax or Letter of
Time of Purchase? Yes No Tax Previously Paid? Yes No Delivery provided? Yes No
The company signatory hereto hereby certifies that it has or will insure or guarantee performance
K. Insurance Information by the applicant herein before named with respect to the motor vehicle herein before described for
a period at least coterminous with that of such registration under a motor vehicle liability policy,
K1. Insurance Company binder or bond which conforms to the provisions of general laws, Chapter 175, Section 113A, and
LIBERTY MUTUAL PERSONAL INSURANCE COMPANY that the premium charge and classification on the effective date of registration are as established
K2. Insurance Code K3. Effective Date of Insurance by the commissioner of insurance under Chapter 175, Section 113B, 113H and Chapter 175E.
525 03/24/2022
LIBERTY MUTUAL PERSONAL INSURANCE COMPANY
K4. Self Insured? Yes No K5. Policy Change Date
04/07/2022
525

L. Seller Information
Insurance Company's Authorized Representative's Signature
L1. Seller Name (Please Print)

L2. Address Apt. # City State Zip Code

M. Certification and Signature of Applicant(s) Application not complete without all required signatures.

I/We the applicants hereby certify under the penalties of perjury that there are no outstanding excise tax liabilities on the vehicle described above that
have been incurred by the applicant(s), any member of the applicant's immediate family who is a member of the applicant's household or the business
partner of the applicant(s). The RMV reserves the right to verify any representations or documents you provide. Whoever knowingly makes any false
statement in application for registration of a motor vehicle is subject to prosecution and a fine and/or imprisonment upon conviction (M.G.L. c.90, §24).
The Registrar may also revoke any registration obtained by false statements or misrepresentations. I hereby affirm under the penalty of perjury that the
representations and/or documents I have provided in this Section are true and accurate. I further understand that falsely affirming to any matter required
by the Registrar under Chapter 90 may be considered to be the commission of perjury under Chapter 90, Section 28 and punished as such under
M.G.L. c. 268, §1.

Signature: Owner/Lessee 1 Date:

Signature: Owner/Lessee 2 Date:

TTLREG100_1119