Form 78 014 10 – Fill Out and Use This PDF

AFFIDAVIT WHEN OWNER DIES

WITHOUT A WILL

Form 78-014-10

Attached to and made a part of the application for assignment of title to a vehicle when the owner dies without a will being probated and no personal representative appointed or widow’s allotment made.

(If minor or mentally incompetent children included among next of kin, the surviving parent may act for such children.)

I/We the undersigned, being first duly sworn, deposes and says:

1.That _______________________________, died on _______ day of ______________________, 20_________ and at the time of his or her death was the sole owner of the following described vehicle:

VIN: __________________________ YEAR: ________ MAKE: ______________________________________________

MODEL: ______________________________ TITLE NUMBER: ______________________________________________

Federal law and State law requires that you state the mileage in connection with the transfer of ownership. Failure to complete or providing false statement may result in fines and/or imprisonment.

I, ___________________________________, state that the odometer now reads __________________ (NO TENTHS) miles

and to the best of my knowledge that the actual mileage of the vehicle described herein, unless one of the following statements is checked:

__ (1) I hereby certify to the best of my knowledge the odometer reading reflects the amount of mileage in excess of its

mechanical limits.

__ (2) I hereby certify that the odometer reading is NOT the actual mileage. WARNING – ODOMETER DISCREPANCY

2.That no will was probated and no administrator, executor or other personal representative has been appointed to administer on his or her estate.

3.That the deceased is survived by ______ Spouse _________ Children _________ Was Unmarried

4.That the following are all of the kin of said deceased:

Printed Name of Kin	Address	Relation	Age
_________________________________	____________________________________________	____________ _______
_________________________________	____________________________________________	____________ _______
_________________________________	____________________________________________	____________ _______
_________________________________	____________________________________________	____________ _______
_________________________________	____________________________________________	____________ _______

5.That it is the desire of the next of kin that said vehicle be assigned and registered in the name of _____________________

____________________________________________________________________________________________________

Title Bureau, P.O. Box 1383 Jackson, MS 39215 www.dor.ms.gov Phone 601-923-7200 FAX 601-923-7224