State of Florida
County of Pasco
Pat-1 (R 12/07)
AFFIDAVIT
The undersigned hereby certifies the following fact(s) regarding vehicle/vessel described:
Make _________ Year _______ ID# ___________________________ Title # ________________
1. My name was entered in error as purchaser on the above referenced title. I have never had
possession or any interest in this vehicle/vessel.
2. The name __________________________ was entered in error as purchaser.
This person never took possession and vehicle/vessel was sold to:
__________________________ for $_____________ on (date) __________.
3. My name was entered in error as lienholder on the above referenced title. I do not hold any
lien against this vehicle.
4. The names __________________________ and __________________________ appearing
on the attached papers identify one and the same person.
5. The above referenced vehicle has not been/will not be operated upon the public highways of
Florida.
6. There is an odometer discrepancy because _______________________________________
__________________________________________________________________________
7. The undersigned hereby certify they are “immediate family” members residing in the same
household and thereby exempt from the $100 Initial Registration Fee on the above
referenced vehicle. Florida Statutes define “immediate family” to include “parents, children,
spouse, or surviving spouse of the member, or any other relative by blood, marriage or
adoption.”
8. Other:
Under penalties of perjury, I declare that I have read the foregoing document and that the
facts stated in it are true.
Date: _______________
___________________________________ ____________________________________
Signature of Affiant Signature of Affiant
___________________________________ ____________________________________
Printed Name of Affiant Printed Name of Affiant
