DEPARTMENT OF REVENUE
DIVISION OF VEHICLE
TOPEKA, KANSAS 66626-0001
Fax # For Liens (785) 296-2383
OWNER’S INFORMATION (Last, First, Middle Initial)
LIENHOLDER INFORMATION: The lienholder listed below certifies that their lien for the vehicle listed herein for
the owner(s) shown above has been satisfied and is hereby released.
Subscribed and Sworn before me this day of , 20 .
Notary Public County
My Commission expires on .
TITLE TO BE MAILED TO:
REQUIRED (Must be completed)