Fill - Free fillable SUPREME COURT OF THE STATE OF NEW YORK (Suffolk County Government) PDF form

CA-4

Page 1 of 6

SUPREME COURT OF THE STATE OF NEW YORK

COUNTY OF SUFFOLK

DENNIS M. BROWN, County Attorney

for the COUNTY OF SUFFOLK,

Plaintiff/Claiming Authority,

AFFIDAVIT OF

DEFAULT

-against-

a ______________, VIN No. _______________________,

_________________________________, and

_________________________________,

Defendant(s),

STATE OF ___________ )

COUNTY OF _____________

) ss.:

_________________________________, being duly sworn, deposes and says:

1. I am a ____________________ (title) for the defendant,

___________________________ duly authorized to do business in the State of New York.

___________________________ maintains a place of business at

________________________________________________. I am familiar with the facts and

circumstances set forth based upon my review of the books and records maintained by

___________________________ that relate to this proceeding.

2. I submit this affidavit in support of ___________________________’S application for

possession of a ________________, Vehicle Identification Number______________________

(the "Vehicle").

3. On __________________, _____________________________ (the "Buyer(s)")

executed a Retail Installment Contract (the "Contract") to finance the purchase of the Vehicle. A

copy of the Contract is attached hereto.

COUNTY OF

YEAR and MAKE

VIN NUMBER

BUYER and CO-BUYER

LIEN HOLDER

STATE

COUNTY

AUTHORIZED AGENT

TITLE OF AGENT

LIEN HOLDER

ADDRESS

LIEN HOLDER

YEAR and MAKE

VIN NUMBER

CONTRACT DATE

BUYER and CO-BUYER

VIN NUMBER

LIEN HOLDER

CA-4 Page 2 of 6

4. The Contract was assigned to ___________________________ for value and before

maturity. The Contract granted ___________________________ a security interest in the Vehicle, which

security interest was duly perfected.

5. The Buyer (s) failed to make his/her/their monthly installment payment due for

________________ and each month thereafter, which failure is a default under the Contract. In

addition, the Vehicle's seizure by the County of Suffolk on _______________, in connection with the

arrest of _________________ was a default under the Contract found under paragraph

________________________. On that same date of the Vehicle’s seizure by the County, under

the Contract the Buyer(s) owed to the Lienholder an outstanding balance of

$_____________________________. See attached statement of what is owed to the

Lienholder.

6. By reason of said default(s), and pursuant to the New York State Uniform Commercial Code

§ 9-609 (formerly § 9-503) and New York State Vehicle and Traffic Law § 425,

___________________________ is asserting its superior right to possession of the Vehicle as against

the subordinate possessory interest of the Buyer(s). Accordingly,

___________________________ is entitled to recover possession of its Vehicle as against the

Buyer(s).

7. ___________________________ respectfully requests that it be permitted to effect an

immediate repossession of the Vehicle.

LIEN HOLDER

PAYMENT DUE DATE

PARAGRAPH LETTER/#

DOLLAR VALUE OUTSTANDING

LIEN HOLDER

VIN NUMBER

LIEN HOLDER

DATE OF SEIZURE OR

ARREST

NAME OF DRIVER/ARRESTEE

CA-4

Page 3 of 6

9. ___________________________ agrees to indemnify and hold harmless the County of

Suffolk from any and all claims which may have been made or may be made in the future by

the Buyer(s), that the County of Suffolk acted improperly

in permitting ___________________________ to recover the Vehicle from the County of

Suffolk.

10. All right, title and possessory interest in the Vehicle, presently held by the Suffolk

County Attorney's Office under the authority of Suffolk County Code Article II of Chapter 420;

Article III of Chapter 818; Article IV of Chapter 818 and/or Article VI of Chapter 818 and Article

13-A of the N.Y.C.P.L.R. will be granted to ___________________________ upon payment of

all applicable towing and storage fees due to the impound facility of the seizing agency for each day

from the date of seizure until the date of release.

11. ___________________________will notify and pay the County of Suffolk within thirty days

of the sale of the subject vehicle any and all surplus proceeds from the sale of the Vehicle

remaining after satisfaction of ___________________________’S lien.

8.___________________________ agrees that the Buyer(s), nor any of his/her/their relatives or

persons residing with him/her/them, are entitled to, nor will they be allowed to, reinstate the installment

contract, negotiate a new installment contract for this Vehicle or regain possession of this Vehicle from

___________________________ unless a Court having proper jurisdiction otherwise orders.

VIN NUMBER

LIEN HOLDER

CA-4

Page 4 of 6

Dated: County, _____________

____________________, 20___

___________________________

STATE OF _____________, COUNTY OF ______________: ss:

On this day __ of _________________ , 20___, before me, the undersigned,

___________________________, personally appeared, personally known to me or proved to me on the

basis of satisfactory evidence to be the individual whose name is subscribed to the within instrument and

acknowledged to me that he/she executed the same in his/her capacity, and that by his/her signature on the

instrument, the individual, or the person upon behalf of which the individual acted, executed the instrument.

_______________________________________

NOTARY PUBLIC

Signature: _______________________

________

Name:______________________________

Print Title:_______________________________

13. Attached please find a copy of both:

i) the Retail Installment Contract, as per paragraph 3 above; and

ii) a billing statement showing what was owed to the Lienholder and outstanding

on the date of the Vehicle’s seizure, as per paragraph 5 above.

12. Nothing contained herein shall effect or impair the rights, duties and obligations under the Contract

as and between __________________________ and the Buyer(s).

LIEN HOLDER

VIN NUMBER

LIEN HOLDER

CA-4

Page 5 of 6

RELEASE

TO ALL TO WHOM THESE PRESENTS SHALL COME OR MAY CONCERN,

KNOW THAT, ___________________________, duly authorized to do business in the State of

New York, with offices located at

_____________________________________________________;

In consideration of the receipt of a ______________, Vehicle Identification Number

_____________________ (the "Vehicle"), from the COUNTY OF SUFFOLK, as RELEASEE;

___________________________, as RELEASOR, hereby releases and discharges the

RELEASEE, RELEASEE'S agents, servants, employees, heirs, executors, administrators,

successors and assigns from all actions, causes of action, suits, debts, dues, sums of money,

accounts, reckonings, bonds, bills, specialties, covenants, contracts, controversies, agreements,

promises, variances, trespasses, damages, judgments, extends, executions, claims, and demands

whatsoever, in law, admiralty or equity, which against the RELEASEE, the RELEASOR, the

RELEASOR'S heirs, executors, administrators, successors and assigns ever had, now have or

hereafter can, shall or may, have for, upon, or reason of any matter, cause or thing whatsoever

from the beginning of the world to the day of the date of this RELEASE, with regard to the

release of the Vehicle to ___________________________ and the condition of the Vehicle as of

the date and time of the Vehicle's seizure, and further agrees:

RELEASOR further represents that it will indemnify and hold harmless the RELEASEE from

any and all actions, causes of action, suits, sums of money, accounts, controversies, agreements,

promises, damages, judgments, extents, executions, claims, and demands whatsoever, in law or

equity, which the owner of the vehicle may bring against the RELEASEE, its successors and

assigns, limited and restricted solely to an indemnity for all claims which were raised, or can be

raised in the future, concerning a claim that the RELEASEE should not have turned possession

of the vehicle and the property contained therein over to the RELEASOR, and any and all claims

against any personnel and/or official of the RELEASEE acting within the scope of their

employment they should not have turned possession of the vehicle and the property contained

therein over to the RELEASOR.

VIN NUMBER

LIEN HOLDER

VIN NUMBER

LIEN HOLDER

ADDRESS

YEAR and MAKE

CA-4

Page 6 of 6

The disposition of this action and this RELEASE are not evidence of nor an admission of any

wrongdoing whatsoever by the RELEASEE or RELEASOR. This RELEASE may not be

changed orally.

In Witness Whereof, the RELEASOR caused this RELEASE to be executed on the ____ day of

___________________________ , 20___.

STATE OF _________________, COUNTY OF __________________: ss:

On this day of ______________________________, 20___, before me, the undersigned,

______________________, personally appeared, personally known to me or proved to me on

the basis of satisfactory evidence to be

the individual whose name is subscribed to the within

instrument and acknowledged to me that he/she executed the same in his/her capacity, and that by

his/her

signature on the instrument, the individual, or the person upon behalf of which the

individual acted, executed the instrument.

Signature:_____________________________

Print Name:___________________________

Print Title:____________________________

________________________________

NOTARY PUBLIC

LIEN HOLDER

VIN NUMBER

LIEN HOLDER

Download
Save PDF to desktop

Email
Email completed PDF

Send for Signing
Email for others to sign

Print
Print document

NAME

SUPREME COURT OF THE STATE OF NEW YORK (Suffolk County Government)

View Audit Log
Print With Audit Log
Duplicate Document

Fill Online, Printable, Fillable, Blank SUPREME COURT OF THE STATE OF NEW YORK (Suffolk County Government) Form

Related forms

Fillable SUPREME COURT OF THE STATE OF NEW YORK (Suffolk County Government)

Fill Online, Printable, Fillable, Blank SUPREME COURT OF THE STATE OF NEW YORK (Suffolk County Government) Form

Related forms

First 20 documents completely FREE!