TENNESSEE DEPARTMENT OF REVENUE
PURPOSE: An individual may use this affidavit for purposes of writing a statement of facts which is sworn
to be true.
INSTRUCTIONS: Please complete form accordingly.
Non-use: the motor vehicle described in this document has not been operated on the roads
or highways of Tennessee.
A. AFFIANT INFORMATION:
Name:___________________________________________________________________ Phone: _________________________
Street Address:___________________________________________ City:___________________ State:_____ Zip: ________
B. VEHICLE INFORMATION:
Vehicle Identification Number (VIN)________________________________________________ Year: ________________
Make:________________________________ Model: _____________________________ Color: ________________________
One in the Same Name: The two different names found on different documents refer to one person.
Correction: An error was made in the title application paperwork. Please explain the error in the
spaces provided below.
AFFIANT CERTIFICATION STATEMENT: I, the undersigned affiant hereby certify that the statements
made herein are true and correct to the best
of my knowledge, information and belief. Fraudulent
statements made in this application could result in denial of this request and subject the signatory to
criminal and civil penalties.
Affiant's Signature: ___________________________________________________________Date: _________________________
State of Tennessee
County of ______________________________________
On this __________________ day of ___________________, 20________, before me personally
to me known to be the person described in and who executed the foregoing instrument, and acknowledged that he/
she executed the same as his/her free act and deed, for the purposes therein set forth.
_______________________________________ (County Clerk)
My Commission Expires _________________________________________, 20______________
C. STATEMENT OF FACTS: