CA-5 _____________________ ____________________ Page 1 of 5
SUPREME COURT OF THE STATE OF NEW YORK
COUNTY OF SUFFOLK
DENNIS M. BROWN, County Attorney
for the COUNTY OF SUFFOLK,
Plaintiff/Claiming Authority,
-against-
a ______________, VIN No. _____________________,
_________________________________, and
___________________________,
Defendant(s),
AFFIDAVIT OF
DEFAULT
STATE OF _________________ )
) ss.:
COUNTY OF ______________
_______________________, being duly sworn, deposes and says:
1. I am a ________________________ (title) for the defendant,
___________________________, duly authorized to do business in the State of New York.
___________________________ maintains a place of business at
_______________________________________________. I am familiar with the facts and
circumstances set forth based upon my review of the books and records maintained by
___________________________ that relate to this proceeding.
2. I submit this affidavit in support of ___________________________’S
application for possession of a ______________, Vehicle Identification Number
_____________________ (the "Vehicle").
3. On __________________, _____________________________ (the "Lessee(s)")
executed a Motor Vehicle Lease Agreement (the "Lease") to lease the vehicle. A copy of the
Lease is attached hereto.
YEAR and MAKE
VIN NUMBER
LESSEE and CO-LESSEE
LIEN HOLDER
STATE
COUNTY
TITLE OF AGENT
LIEN HOLDER
LIEN HOLDER
ADDRESS
LIEN HOLDER
LIEN HOLDER
YEAR and MAKE
VIN NUMBER
LEASE DATE
LESSEE and CO-LESSEE
VIN NUMBER
LIEN HOLDER
CA-5 _____________________ ____________________ Page 2 of 5
4. The Lease was assigned to ___________________________ for value and before
maturity. The Lease provides that ___________________________ is the owner of the Vehicle,
as is reflected in the records of the New York State Department of Motor Vehicles.
5. The Lessee(s) failed to make his/her/their monthly lease payment due for
_________________ and each month thereafter, which failure is a default under the Lease. In
addition, the Vehicle's seizure by the County of Suffolk on ______________, in connection with
the arrest of _____________________ was a default under the Lease.
6. By reason of said defaults, and pursuant to the New York State Uniform
Commercial Code § 9-609 (formerly § 9-503) and New York State Vehicle and Traffic Law §
425, ___________________________ is asserting its superior right of possession to the Vehicle
as against the subordinate possessory interest of the Lessee(s). Accordingly,
___________________________ is entitled to recover possession of its Vehicle as against the
Lessee(s).
7. ___________________________ respectfully requests that it be permitted to
effect an immediate repossession of the Vehicle.
8. ___________________________ agrees that Lessee(s), nor any of his/her/their
relatives or persons residing with him/her/them, are entitled to, nor will they be allowed to,
reinstate the Lease, negotiate a new installment contract or lease for this Vehicle with
___________________________ or regain possession of this Vehicle from
___________________________ unless a Court having proper jurisdiction otherwise orders.
9. ___________________________ agrees to indemnify and hold harmless the
County of Suffolk from any and all claims which may have been made or may be made in the
LIEN HOLDER
LIEN HOLDER
PAYMENT DUE DATE
LIEN HOLDER
LIEN HOLDER
LIEN HOLDER
LIEN HOLDER
LIEN HOLDER
LIEN HOLDER
LIEN HOLDER
VIN NUMBER
LIEN HOLDER
CA-5 _____________________ ____________________ Page 3 of 5
future by the Lessee(s), any claim that the County of Suffolk acted improperly in permitting
___________________________ to recover the Vehicle from the County of Suffolk.
10. All right, title and possessory interest in the Vehicle, presently held by the Suffolk
County Attorney's Office under the authority of Suffolk County Code Article II of Chapter 420;
Article III of Chapter 818; Article IV of Chapter 818 and/or Article VI of Chapter 818 and
Article 13-A of the N.Y.C.P.L.R. will be granted to ___________________________ upon
payment of all applicable towing and storage fees due to the impound facility of the seizing
agency for each day from the date of seizure until the date of release.
11. ___________________________ will notify the County of Suffolk within thirty
days of the sale of the subject vehicle of any and all surplus proceeds from the sale of the
Vehicle remaining after satisfaction of ___________________________’S outstanding balance
12. Nothing contained herein shall effect or impair the rights, duties and obligations
under the Lease as and between ___________________________ and the Lessee(s).
Dated: County, ______________
, 20___
___________________________
By: _______________________
STATE OF ________________, COUNTY OF ________________: ss:
On this day of , 20___, before me, the undersigned,
_____________________, personally appeared, personally known to me or proved to me on the
basis of satisfactory evidence to be the individual whose name is subscribed to the within
instrument and acknowledged to me that he/she executed the same in his/her capacity, and that
by his/her signature on the instrument, the individual, or the person upon behalf of which the
individual acted, executed the instrument.
_______________________________________
NOTARY PUBLIC
LIEN HOLDER
LIEN HOLDER
LIEN HOLDER
LIEN HOLDER
LIEN HOLDER
LIEN HOLDER
VIN NUMBER
LIEN HOLDER
AUTHORIZED AGENT NAME, SIGN ABOVE
CA-5 _____________________ ____________________ Page 4 of 5
RELEASE
TO ALL TO WHOM THESE PRESENTS SHALL COME OR MAY CONCERN,
KNOW THAT, ___________________________, duly authorized to do business in the
State of New York, with offices located at
_____________________________________________________;
In consideration of the receipt of a ______________, Vehicle Identification Number
_____________________ (the "Vehicle"), from the COUNTY OF SUFFOLK, as RELEASEE;
___________________________, as RELEASOR, hereby releases and discharges the
RELEASEE, RELEASEE'S agents, servants, employees, heirs, executors, administrators,
successors and assigns from all actions, causes of action, suits, debts, dues, sums of money,
accounts, reckonings, bonds, bills, specialties, covenants, contracts, controversies, agreements,
promises, variances, trespasses, damages, judgments, extends, executions, claims, and demands
whatsoever, in law, admiralty or equity, which against the RELEASEE, the RELEASOR, the
RELEASOR'S heirs, executors, administrators, successors and assigns ever had, now have or
hereafter can, shall or may, have for, upon, or reason of any matter, cause or thing whatsoever
from the beginning of the world to the day of the date of this RELEASE, with regard to the
release of the Vehicle to ___________________________ and the condition of the Vehicle as of
the date and time of the Vehicle's seizure, and further agrees: RELEASOR further
represents that it will indemnify and hold harmless the RELEASEE from any and all actions,
causes of action, suits, sums of money, accounts, controversies, agreements, promises, damages,
judgments, extents, executions, claims, and demands whatsoever, in law or equity, which the
owner of the vehicle may bring against the RELEASEE, its successors and assigns, limited and
restricted solely to an indemnity for all claims which were raised, or can be raised in the future,
LIEN HOLDER
ADDRESS
YEAR and MAKE
VIN NUMBER
LIEN HOLDER
LIEN HOLDER
VIN NUMBER
LIEN HOLDER
CA-5 _____________________ ____________________ Page 5 of 5
concerning a claim that the RELEASEE should not have turned possession of the vehicle and the
property contained therein over to the RELEASOR, and any and all claims against any personnel
and/or official of the RELEASEE acting within the scope of their employment they should not
have turned possession of the vehicle and the property contained therein over to the
RELEASOR.
The disposition of this action and this RELEASE are not evidence of nor an admission of
any wrongdoing whatsoever by the RELEASEE or RELEASOR. This RELEASE may not be
changed orally.
In Witness Whereof, the RELEASOR caused this RELEASE to be executed on the ____
day of , 20___
___________________________
By: _________________________________
STATE OF _________________, COUNTY OF __________________: ss:
On this day of , 20___, before me, the undersigned,
______________________, personally appeared, personally known to me or proved to me on the
basis of satisfactory evidence to be the individual whose name is subscribed to the within
instrument and acknowledged to me that he/she executed the same in his/her capacity, and that
by his/her signature on the instrument, the individual, or the person upon behalf of which the
individual acted, executed the instrument.
_______________________
NOTARY PUBLIC
LIEN HOLDER
VIN NUMBER
LIEN HOLDER
AUTHORIZED AGENT NAME, SIGN ABOVE