Whose address is this ,
does hereby make, constitute and appoint ,
whose address is ,
as the lawful attorney in fact, to sign all papers and documents required to secure Illinois title and/or registration of, or transfer
interest in, the following described vehicle:
Vehicle Make: Model Year:
Vehicle Model: Body Type:
Vehicle Identification Number (VIN)
Complete the following (if applicable):
Purchaser’s Name:
Address:
Date of Sale:
Granting to the aforesaid attorney in fact full power to do all acts as the principal might or could do if personally present; and
hereby ratifying and confirming all that said attorney in fact shall lawfully do or cause to be done by virtue of the authority
herein givin for this purpose, under penalties of perjury.
Such authority shall in no way reflect upon the State of Illinois, Secretary of State, or the Director of the Vehicle Services
Department.
Signed
Date Signed
Secretary of State
Power of Attorney
Secretary of State
Vehicle Services Department
501 S. Second St.
Springfield, IL 62756
www.cyberdriveillinois.com
This space for use by
Secretary of State
Printed by authority of the State of Illinois. April 2021 — 1 — RT 5.12
Name%of%individual%appointing%power%of%attorney
,
