Motor Vehicle Ownership Affidavit – Fill Out and Use This PDF

THE STATE OF MISSISSIPPI, COUNTY OF ________________________________________________________________

Before me the undersigned has this day appeared ________________________, of ________________________________

NameStreet Address

Owner by virtue of the attached bill of sale of the following described vehicle

VIN: __________________________ YEAR: ________ MAKE: _______________________________________________

And states that said vehicle was acquired from _________________________________________________, whose address

(Enter Name of Person You Acquired Vehcile From; Attach Bill of Sale)

is __________________________________ City ______________________ State __________________ Zip ___________

Telephone number at which the seller may be reached: (______) _______________. In what state was the herein described

(Required)

vehicle last registered? ________________________________________________________________________________

(Required)

In your own words, state the reason you are unable to surrender the current Certificate of Title of the vehicle. ____________

____________________________________________________________________________________________________

Was there a license tag on the vehicle when you acquired it? ___________ If so, give state and tag number. _____________

Instructions

The vehicle described herein must be taken to the nearest Mississippi Department of Public Safety substation for inspection and issuance of Form MVCT-59 by the inspecting officer prior to making application for certificate of title.

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

_______________________________________________

(Printed Name of Buyer)

_______________________________________________

(Signature)

SUBSCRIBED AND SWORN TO BEFORE ME THIS ________ day of ____________________________, 20_______.

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