Form 78-010-17-8-1-000 Rev(09/17)
AFFIDAVIT OF SALE UNDER LIEN
THE STATE OF MISSISSIPPI, COUNTY OF , DATE
OR OR
(Name of Lienholder) (Pres., V. Pres., Sec-Treas.) (Manager)
owner and holder of an indebtedness owed by
(Name of Person Owning Indebtedness)
of secured by lien on Motor Vehicle described in certificate of
(Address)
Title Number , Vehicle Identification Number (VIN)
Default having been made, the undersigned foreclosed the lien in the manner provided by law and by the terms of the lien
instrument and sold the vehicle described to
(Name of Buyer)
on at
(Address)
(Date)
(Place of Sale)
for $
(Consideration)
The undersigned states that all applicable laws of the State of Mississippi, as well as the applicable laws of any other state
where the Vehicle may have been repossessed, have been fully complied with, and the undersigned further states and
guarantees that the purchaser has good Title to the Vehicle which is warranted subject to the following liens:
, ,
AND AFFIANT FURTHER STATES;
Federal law and State law requires that you state the mileage in connection with the transfer of ownership. Failure to
complete or providing false statement may result in fines and/or imprisonment.
I, , state that the odometer now reads (NO TENTHS) miles and to the
best of my knowledge that the actual mileage of the vehicle described herein, unless one of the following statements is checked:
(1) I hereby certify to the best of my knowledge the odometer reading reflects the amount of mileage in excess of its mechanical limits.
(2) I hereby certify that the odometer reading is NOT the actual mileage. WARNING – ODOMETER DISCREPANCY
(Printed Name of Seller) (Printed Name of Buyer)
(Signature) (Signature)
SUBSCRIBED AND SWORN TO BEFORE ME THIS day of , 20 .
SEAL
(Notary Public)
Motor Vehicle Services P.O. Box 1383 Jackson, MS 39215 www.dor.ms.gov
Phone 601-923-7200 FAX 601-923-7224
Mississippi
