RELEASE OF LIEN / TRANSFER OF OWNERSHIP

AFFIDAVIT

On this ___ day of ________, 2002, I/we, authorized agent(s) and representative(s) of
LIEN HOLDER COMPANY, of and for PERSON, TITLE, with legal authority to transact all
business, for valuable consideration already paid to LIEN HOLDER COMPANY, the receipt of
which is hereby acknowledged, do hereby remise, release and forever release all liens and
transfer unencumbered ownership to <YOUR NAME> of the following described vehicle:
MAKE: MODEL:
BODY TYPE: YEAR:
VEHICLE IDENTIFICATION NO.:
LICENSE NUMBER:
ODOMETER READING ON DATE:

LIEN HOLDER COMPANY BY:

Signature of Lien Holder Agent Printed Name and Title:

Signature of Lien Holder Agent: Printed Name and Title:

STATE OF )
)ss.
COUNTY OF )

On the ____ day of ________, 2002 A.D., before me, ,

(personally known to me, or) proved to me on the basis of satisfactory evidence to be the person whose name is
subscribed to the within instrument and acknowledged to me that he or she executed the same in his or her
authorized capacity and that by his or her signature on the instrument, the person or the entity upon behalf of
which the person acted, signed under oath or asseveration, and accepts the truth thereof.

My commission expires
Notary Public Signature

Seal:

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