Motor Vehicle Services P.O. Box 1383 Jackson, MS 39215 www.dor.ms.gov
Phone 601-923-7200 FAX 601-923-7224
THE STATE OF MISSISSIPPI, COUNTY OF ________________________________________________________________
Before me the undersigned has this day appeared ________________________, of ________________________________
Name Street Address
_____________________, _____ _____________ who after being duly sworn, deposes and states that he (she) is the legal
City State Zip
Owner by virtue of the attached bill of sale of the following described vehicle
VEHICLE IDENTIFICATION NUMBER (VIN): ______________________________ YEAR: ________ MAKE: __________
And states that said vehicle was acquired from _________________________________________________, whose address
(Enter Name of Person You Acquired Vehcile From; Attach Bill of Sale)
is __________________________________ City ______________________ State __________________ Zip ___________
Telephone number at which the seller may be reached: (______) _______________. In what state was the herein described
(Required)
vehicle last registered? ________________________________________________________________________________
(Required)
In your own words, state the reason you are unable to surrender the current Certificate of Title of the vehicle. ____________
____________________________________________________________________________________________________
Was there a license tag on the vehicle when you acquired it? ___________ If so, give state and tag number. _____________
Instructions
If the vehicle described herein is ten (10) model years or less, it must be taken to the nearest Mississippi Department of
Public Safety substation for inspection and issuance of Form MVCT-59 by the inspecting officer prior to making application
for certificate of title.
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 Buyer)
_______________________________________________
(Signature)
SUBSCRIBED AND SWORN TO BEFORE THIS ________ day of ____________________________, 20_______.
________________________________________
(Notary Public)
Form 78-013-18-8-1-000 Rev (07/18)
Mississippi
AFFIDAVIT OF OWNERSHIP OF MOTOR VEHICLE FOR WHICH APPLICATION
FOR TITLE UNDER BOND OR CASH IS MADE
