TENNESSEE DEPARTMENT OF REVENUE
Insurance Verification Affidavit
RVF-00114 (Rev.3-20)
PURPOSE: An individual may use this affidavit for purposes of writing a statement of facts which is sworn
to be true.
INSTRUCTIONS: Please complete the affidavit in its entirety.
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: ________________________
Vehicle Sold: Vehicle is no longer owned by the person currently listed on the Tennessee record
Registrant Out of State: Registrant no longer lives in the state of Tennessee
Other/Further Details:
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: _________________________
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