Jesse White
Secretary of State
AFFIRMATION
NON-RECEIPT OF TITLE
Date ______________________________ , ________
Year
Name of Owner(s) 1) _______________________________________________________________
2) _______________________________________________________________
Street and No. of R.F.D. ______________________________________________________________
City ____________________________________ State _________ ZIP Code ________________
DOES HEREBY AFFIRM THAT HIS/HER/THEIR VEHICLE
________________________, ______________, ____________________________, ____________
Vehicle Identification Number Year Make & Model Body Style
WAS PURCHASED ON ________________________. THE TITLE HAS NEVER BEEN RECEIVED
FROM THE SECRETARY OF STATE, EVEN THOUGH THEIR RECORDS DO INDICATE THAT THE
TITLE WAS MAILED.
I/We hereby affirm that the information provided is true and correct.
Signature of Owner(s) (1) ____________________________________________________________
(2) ____________________________________________________________
Printed by authority of the State of Illinois November 2013 — 2.5M — VSD-252.4
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