3/2022
PURCHASER’S
AFFIDAVIT
Application for title for the following described motor vehicle or trailer is being made:
(Year) (Make) (VIN)
The undersigned, being duly sworn, depose or affirm that the following is true about the above-
described motor vehicle or trailer:
This motor vehicle or trailer was purchased from on
.
Certificate of Title # which was originally assigned
to has been lost or mutilated.
The undersigned has requested that the above-named dealership make application for a
new original certificate of title for the purposes of assigning ownership.
DATED this day of , .
Subscribed and sworn to before me this day of ,
(Notary Public or Designated County Official)
This completed, signed and notarized affidavit is required to be submitted by a licensed motor vehicle or
trailer dealer with an Application for Certificate of Title and photocopy from the dealer’s records of the
front and back of the lost or mutilated original certificate of title which was assigned to the dealer
showing a reassignment to the above Purchaser.
Filin
g of a false affidavit violates the provisions of the Motor Vehicle Registration Act. Any
person, firm, association, partnership, Limited Liability Company or corporation that does so may
be subject to prosecution.
Name of Last Seller
Date of Purchase
Title Number
Name(s) of Purchaser
Signature of Last Selling Dealer
