County of ______________________________________________ Date ___________________________
Under penalties of perjury, the undersigned, duly sworn, deposes and says that the owner of the motor
vehicle described as:
Make _________________________ VIN _________________________________________________
Model __________________ Body ______________________ Yr. Model ____________________
died on the _______________________ day of ________________________ in ____________________
County of ____________________________________________________, Tennessee. That the deceased,
___________________________________________________________________________, left no estate
Name of Deceased
necessitating administration and no letters testamentary or of administration have been issued to any
person. There are no debts or encumbrances remaining unpaid, which are or may become a lien on said
vehicle, except _________________________________________________________________________
(Describe fully any liens or debts that might become a lien)
and that by mutual agreement of all the heirs and next of kin who are parties hereto vest the ownership of
said vehicle to:
__________________________________________ __________________________________________
Signature Printed Name
______________________ ______________________________________________________________
Date Complete Mailing Address
and the undersigned (all heirs or next of kin) relinquish any and all claims in or to said motor vehicle:
Signature Printed Name Date
Signature Printed Name Date
Signature Printed Name Date
Sworn to and subscribed before me this the __________________________________________ day of
______________________________, 20____________________.
(Clerk or Notary Public)
My commission expires: _________________________________________________________________
NOTE: Any heir (or heirs) that was (were) not present at time of this execution should attach separate
affidavit relinquishing his (their) claim to said vehicle, or power of attorney granted authority for another to
sign for them. Rule 1340-5-13-.02(2)(b), T.C.A. 55-4-101
RV-F1310501 (Rev. 12-10)
Tennessee Department of Revenue
Taxpayer and Vehicle Services Division
44 Vantage Way, Suite 160
Nashville, TN 37243-8050
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