MINNESOTA DEPARTMENT OF PUBLIC SAFETY
DRIVER AND VEHICLE SERVICES
445 Minnesota Street, Suite 187
Saint Paul, MN 55101-5187
Phone: (651) 297-2126 TTY: (651) 282-6555
Web: dvs.dps.mn.gov
AFFIDAVIT OF REPOSSESSION / TITLE APPLICATION
FOR OFFICE USE ONLY
Please read the instructions on the reverse side before completing this form.
TYPE
YEAR
VEHICLE IDENTIFICATION NUMBER
PLATE NUMBER
NAME OF REGISTERED OWNER(S) TITLE NUMBER
STREET ADDRESS CITY STATE ZIP CODE
MAKE
MODEL
TITLE FEE
FILING FEE
TOTAL TAX DUE
PS2024-14 Rev. 05/18
-OVER-
FOR CENTRAL OFFICE USE ONLY
ZIP CODESTATECOUNTY CODECITYSTREET ADDRESS
PSV FEE
I, the undersigned, on oath duly sworn, depose and say that,
DATE OF REPOSSESSIONNAME OF SECURED PARTY
Is the owner of the vehicle described above. The interest of the owner was lawfully terminated and disposition made pursuant to the terms of the security
agreement. This application for a Certificate of Title is based on the repossession of this motor vehicle.
I further state that in consideration of the issuance of the certificate of title applied for, we hereby agree to indemnify the registrar of motor vehicles, and all
persons acting for him from any and all liability which may be incurred by the issuance of such certificate and agree, at our own expense, to defend any suit
which may be brought against the registrar or any person acting for him as a result of Issuing such certificate. I hereby certify I have taken all possible steps to
secure the title to the above described vehicle.
EXP. DATEPOLICY NUMBERAUTO INSURANCE COMPANY
ODOMETER DISCLOSURE STATEMENT
(no tenths) Miles
I hereby certify to the best of my knowledge the odometer reading
reflects the amount of mileage in excess of its mechanical limits.
DAMAGE DISCLOSURE STATEMENT
Has
sustained damage in excess of 80% actual cash value
Has Not
And to the best of my knowledge that it reflects the actual mileage of the
vehicle described herein unless one of the following statements is checked.
I hereby certify that the odometer reading is not the actual mileage.
SUBSCRIBED AND SWORN BEFORE ME THIS
DAY OF
, 20
NOTARY PUBLIC SIGNATURE
COUNTY
MY COMMISSION EXPIRES
(select one)
WARNING: Odometer discrepancy if box (1) or (2) is checked.
I (we) state that the odometer now reads
To the best of my knowledge this vehicle:
I declare this tax
exemption code:
If needed, ID
number:
Signature of Secured Party
X
NOTARY STAMP
