(Rev. 09/12)
The following questions must be answered in detail and this form must be attached to any application for title
that is supported by an Indemnity Bond. Furnish any document in your possession showing proof of ownership.
(Examples would be a Title, Bill of Sale, Conditional Sales Contract, Invoices, Out of State Registrations).
Year Make Body Style Vehicle Identification Number
1. How did you acquire the vehicle? List the seller’s full name, full address, and phone number.
2. List the date you acquired the vehicle.
3. Is the vehicle currently titled in North Carolina? If no, list the last title state.
4. Does the VIN plate appear on the vehicle? If so, please give the location.
5. Are there any liens outstanding on the vehicle? If so, list the lienholder’s name and provide a lien release.
6. Has the vehicle been wrecked? If so, list the major parts replaced.
7. If you were given a title at the time of purchase, why can it not be furnished at the present time?
8. Explain, in detail, why the seller did not give you a properly assigned title for the vehicle.
9. What steps have you taken to contact the seller/previous owner to obtain proper ownership documentation?
I (we) certify that the above information is correct to the best of my knowledge.
OWNER’S SIGNATURE _________________________________________________________________________
Date ______________ County _________________________________________ State ______________________
I certify that the following person(s) personally appeared before me this day, each acknowledging to me that he or
she voluntarily signed the foregoing document for the purpose stated therein and in the capacity indicated.
____________________________________________________________________ [NAME(S) OF PRINCIPALS(S)]
Notary Notary Printed
Signature _______________________________________ or Typed Name _________________________________
(SEAL) My Commission Expires __________________________
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