Comes the Affiant _______________________________________________________________
(Printed Name)
Who, being duly sworn, deposes and says, to wit as follows:
Further Affiant Saith Not
Signature of Affiant
State of Tennessee
County of ____________________________
On this __________________ day of ___________________, 20________, before me personally
to me known to be the person described in and who executed the foregoing instrument, and
acknowledged that he/she executed the same as his/her free act and deed, for the purposes therein
set forth.
(County Clerk) (Notary Public)
My Commission Expires _________________________________________, 20______________
RV-F1311001 (4/02)
RDA 692
State of Tennessee
Department of Revenue
Taxpayer and Vehicle Services Division
44 Vantage Way, Suite 160
Nashville, Tennessee 37243-8050