OATH
AND
ACKNOWLEDG-
MENT
STATEMENT
OF
IDENTITY
MOTOR VEHICLE OWNERSHIP AFFIDAVIT
H-115 Rev. 10-2014
STATE OF CONNECTICUT
DEPARTMENT OF MOTOR VEHICLES
TITLE UNIT
FULL NAME(S) (First, Middle Initial, Last)
RESIDENT ADDRESS (Number and Street) (City or Town) (State)
(Zip Code)
VEHICLE
DESCRIPTION
YEAR MAKE
MODEL
VEHICLE IDENTIFICATION NUMBER (VIN)
I (we) are the lawful owners of the above described vehicle. I (we) do not have knowledge of any liens or encumbrances
on the said vehicle, except as indicated above. I (we) understand that the statements made herein to the Commissioner
are given under penalty of false statement, in accordance with the provisions of sections 14-110 and 53a-157b of the
Connecticut General Statutes, as amended. I (we) further understand that the Commissioner may revoke any certificate
of title and/or registration issued in reliance on the statements made herein, if the Commissioner becomes aware of any
contrary or additional material facts, and that, in such event, I may have liability to any third person (or persons) or party
(or parties) who has (have) a legal interest in the above described vehicle. I understand that if I make a statement which
I do not believe to be true, with the intent to mislead the Commissioner, I will be subject to prosecution under the
above-cited laws.
OWNERSHIP
STATUS
I (WE) CAME INTO POSSESSION AND OWNERSHIP OF THE ABOVE DESCRIBED VEHICLE AS FOLLOWS (Include name of prior owner, seller, or transferor)
TO THE BEST OF YOUR KNOWLEDGE, ARE THERE ANY LIENS OR ENCUMBRANCES ON THE ABOVE DESCRIBED VEHICLE?
NO YES (If "YES", indicate names and addresses below)
LIEN
STATUS
PRINTED NAME(S) OF OWNER(S)
SIGNATURE(S) OF OWNER(S)
X
DATE SIGNED
