PS2017-10 (6/11)
(Instructions on reverse side)
YEAR MAKE TYPE MODEL VEHICLE IDENTIFICATION NUMBER TITLE NUMBER
OWNER(S) NAME SECURED PARTY’S NAME
STREET ADDRESS STREET ADDRESS
CITY
ZIP CODE
STATECITY
ZIP CODE
SIGNATURE OF OWNER(S), NECESSARY ONLY WITH GRANT
A
SIGNATURE AND TITLE OF AUTHORIZED AGENT
--- NOTICE ---
This form must be notarized
to release a lien.
ASSIGNMENT
RELEASE
GRANT
The secured party named in Section A has assigned his interest to the secured
party named in Section B.
The secured party named in Section A no longer claims a security interest in the
vehicle described above. Date of Release
The owner(s) have granted to the secured party named in Section A, a security
interest in the vehicle described above.
Date of Security Agreement
Subscribed and sworn to before me
this
day of 20
ASSIGNEE’S NAME, NECESSARY ONLY WITH ASSIGNMENT
STREET ADDRESS
B
CITY
ZIP CODE
NOTARY PUBLIC
COUNTY
MY COMMISSION EXPIRES
- over -
Notification of Assignment, Release or Grant of Secured Interest
MINNESOTA DEPARTMENT OF PUBLIC SAFETY
DRIVER AND VEHICLE SERVICES
445 Minnesota Street
Saint Paul, MN 55101-5187
Phone: (651) 297-2126
Web: dvs.dps.mn.gov
STATE
X
X
STATE
