Affidavit for Affirmation of Ownership of a Salvaged Vehicle Obtained

7/2017

Note: This Affidavit is required to be submitted along with the Application for Certificate of Title, evidence of lien

release (when applicable), Odometer Disclosure Statement (when applicable) and evidence of the total loss settlement

(e.g. settlement letter, signed settlement agreement, copy of front and back of cancelled settlement check, etc.).

Affidavit for Affirmation of

Ownership of a Salvaged Vehicle

Obtained in Settlement of a Total

Loss

Application for certificate of title for the following described salvage branded vehicle is being made:

(Year) (Make) (Model/Series) (VIN)

The undersigned, being duly sworn, depose or affirm that the following is true about the above -

described vehicle:

1. It has been at least thirty days since oral or written acceptance of the total loss settlement.

a. Date of Settlement:

2. At least two written attempts to obtain a properly endorsed certificate of title for the above

referenced vehicle have been made.

1. Date of first written notice:

2. Date of second written notice:

3. Ownership was acquired, through the total loss settlement process, from:

Name of Previous Owner Address of Previous Owner

Name of Insurance Company:

Address, City, State Zip:

DATED this day of , .

Printed Name of Insurance Company Representative Signature of Insurance Company Representative

Subscribed and sworn before me this day of , .

(Notary Public or Designated County Official)