Dr2174 Form PDF Details

Form Dr2174 is a form that is used to request an administrative hearing. The form is used to notify the social security administration of your intent to appeal a decision made by the agency. The form must be completed and filed within sixty days of the date of the determination you are appealing. Failure to file the form within the required timeframe will result in the loss of your right to appeal. If you have any questions about how to complete or file Form Dr2174, please consult with an attorney or contact the social security administration directly.

QuestionAnswer
Form NameDr2174 Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesdr2174, colorado form dr 2174, esignature co dr2174, colorado dr2174

Form Preview Example

DR2174 (12/22/09)

No. 000000

STATE OF COLORADO

POWER OF ATTORNEY FOR A MOTOR VEHICLE

ANY ALTERATION OR ERASURE VOIDS THIS POWER OF ATTORNEY

•Colorado licensed motor vehicle dealers shall use this form when the title is physically held by a lienholder or the original title has been lost.

•This form may be used by an individual or entity to sign as both the buyer and seller to acknowledge the odometer reading.

•This form must be submitted with the title application documents.

•Federal and state law requires that you state the mileage in connection with the transfer of ownership.

•Failure to complete or providing a false statement may result in fines and/or imprisonment and may make you liable to your transferee pursuant to 49 U.S.C. 32709.

VEHICLE IDENTIFICATION NUMBER (VIN)

VEHICLE YEAR

MAKE

BODY TYPE

TRANSFEREE'S (DEALER/BUYER) PRINTED NAME

TRANSFEREE'S ADDRESS (STREET, CITY, STATE, ZIP)

ODOMETER DISCLOSURE STATEMENT

CURRENT ODOMETER READING

(NO TENTHS OF MILES)

TO THE BEST OF MY KNOWLEDGE:

THE ODOMETER READING IS THE ACTUAL MILEAGE OF THE VEHICLE.

THE ODOMETER READING IS IN EXCESS OF ITS MECHANICAL LIMITS.

THE ODOMETER READING IS NOT THE ACTUAL MILEAGE - WARNING -

ODOMETER DISCREPANCY.

I, as transferor, appoint the transferee as my attorney-in-fact to disclose the mileage for the vehicle described above, exactly as stated in my disclosure, and to transfer my interest in the vehicle described above. I further certify, under penalty of perjury in the second degree, that the information on this document is true and correct to the best of my knowledge.

TRANSFEROR'S (SELLER’S) SIGNATURE

DATE

TRANSFEROR'S (SELLER’S) HAND PRINTED NAME

TRANSFEROR'S (SELLER’S) SIGNATURE

DATE

TRANSFEROR'S (SELLER’S) HAND PRINTED NAME

TRANSFEROR'S ADDRESS (STREET, CITY, STATE, ZIP)

TRANSFEREE'S (DEALER AGENT/BUYER) SIGNATURE

DATE

TRANSFEREE'S (DEALER AGENT/BUYER) HAND PRINTED NAME

I CERTIFY UNDER PENALTY OF PERJURY IN THE SECOND DEGREE, THAT I HAVE RECEIVED AND REVIEWED THE TITLE

FOR THE VEHICLE DESCRIBED ABOVE AND THAT THERE ARE NO INDICATIONS OF MILEAGE DISCREPANCIES.

SIGNATURE OF PERSON EXERCISING POWER OF ATTORNEY

DATE

HAND PRINTED NAME OF PERSON EXERCISING POWER OF ATTORNEY

ADDRESS (STREET, CITY, STATE, ZIP) OF PERSON EXERCISING POWER OF ATTORNEY

WITH TITLE

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Completing part 1 of colorado power of attorney for motor vehicle

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