Buyer's Name/Names (last, first, and middle)
Incorrect Buyer's Name/Names (last, first, and middle)
MINNESOTA DEPARTMENT OF PUBLIC SAFETY
DRIVER AND VEHICLE SERVICES DIVISION
445 MINNESOTA ST. SUITE 165 ST. PAUL, MN 55101-5165
Phone: (651) 297-2126 TTY: (651) 282-6555 Website: dvs.dps.mn.gov
AFFIDAVIT TO CORRECT THE OWNERSHIP RECORD OF A MOTOR VEHICLE
PLEASE READ THE FOLLOWING INSTRUCTIONS BEFORE COMPLETING THIS FORM:
The appropriate parties must complete all sections of this form and the following:
• Titled vehicle – The seller(s) and correct buyer(s) must also complete the transfer and application on a motor vehicle application (PS2000).
• Non-titled vehicle – A motor vehicle application (PS2000) must be completed and signed by the correct buyer.
Note: To qualify for a refund, cancellation of a vehicle sale must be submitted within 90 days of the initial sale date.
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
Year
Make
Model
Title Number Plate Number
Date(s) of Birth
Secured Party's Name
City State Zip Code
Subscribed and sworn to before me
this ______ day of _______________ 20 _____
Notary Public
County
My Commission Expires
The secured Party named no
longer claims a security
interest in the vehicle above.
Date of Release
Date(s) of Birth
Street Address City State Zip Code
YES NO
Zip CodeStateCity
First Secured Party (Print Name) Date of Loan
Street Address
ACTUAL MILEAGE
IN EXCESS OF ODOMETER'S
MECHANICAL LIMITS
HAS NOT (CHECK ONE)
HAS
NOT ACTUAL MILEAGE -
WARNING ODOMETER DISCREPNCY
Date of Purchase
PS2025-B1 (05/18)
VEHICLE DESCRIPTION MUST BE COMPLETED IN ALL CASES
VEHICLE IDENTIFICATION NUMBER
INCORRECT BUYER(S) MUST COMPLETE THIS SECTION
A
On (provide date)
Signature(s) [INCORRECT BUYER(S) MUST SIGN]
X X
LIEN RELEASE FOR INCORRECT BUYER(S) - Must be Notarized
Signature and Title of Authorized Agent
Note: If a lien is noted on the certificate of title, a lien release is required for the incorrect buyer (The correct buyer must complete the lien information in
Section C below).
X
B
CORRECT BUYER(S) MUST COMPLETE THIS SECTION
C
IS THIS VEHICLE SUBJECT TO SECURITY AGREEMENT(S)? IF YES, COMPLETE SECTION BELOW:
FOR ADDITIONAL SECURED PARTIES, ATTACH
COMPLETED FORM #PS2017
ODOMETER DISCLOSURE STATEMENT. I/WE CERTIFY THAT THE ODOMETER
NOW READS
AND TO THE BEST OF MY KNOWLEDGE THE ODOMETER MILEAGE IS
:
(NO TENTHS) MILES
DAMAGE DISCLOSURE STATEMENT. TO THE BEST OF
MY KNOWLEDGE THIS VEHICLE
SUSTAINED DAMAGE IN EXCESS OF 80 PERCENT ACTUAL
CASH VALUE.
ASSIGNMENT: I/WE CERTIFY THAT THIS VEHICLE IS FREE FROM ALL SECURITY INTERESTS. I/WE WARRANT TITLE AND ASSIGN THE REGISTRATION TAX AND VEHICLE TO
THE PERSON(S) NAMED ABOVE.
X
Signature(s) [CORRECT BUYER(S) MUST SIGN]
X
I/WE DID PURCHASE THE ABOVE DESCRIBED VEHICLE SUBJECT TO LIENS SHOW, AND NO OTHERS:
SELLER(S) MUST COMPLETE THIS SECTION
Seller's Full Name Listed Dealer's Full Name
I/WE CERTIFY THAT ALL INFORMATION ABOVE IS CORRECT:
D
Seller's Signature
X
Listed Dealer's Signature
X
