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    Instructions: This Affidavit Should Be Executed by The Person

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    spcbanking
    The document is an affidavit form for a security interest or lien holder to satisfy a lien on a vehicle, requiring information about the lien holder, vehicle owner, and vehicle identified by year, make, VIN, and title details. The lien holder signs the affidavit under penalty of perjury and it must be notarized, then attached to an application for a certificate of title.

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    Instructions: This Affidavit Should Be Executed by The Person

    Uploaded by

    spcbanking
    211 views1 page
    The document is an affidavit form for a security interest or lien holder to satisfy a lien on a vehicle, requiring information about the lien holder, vehicle owner, and vehicle identified by year, make, VIN, and title details. The lien holder signs the affidavit under penalty of perjury and it must be notarized, then attached to an application for a certificate of title.

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    MVD_Notice_of_Lien_or_Security_Interest_Satisfaction_T4_0.pdf

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    The document is an affidavit form for a security interest or lien holder to satisfy a lien on a vehicle, requiring information about the lien holder, vehicle owner, and vehicle identified by year, make, VIN, and title details. The lien holder signs the affidavit under penalty of perjury and it must be notarized, then attached to an application for a certificate of title.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    211 views1 page

    Instructions: This Affidavit Should Be Executed by The Person

    Uploaded by

    spcbanking
    The document is an affidavit form for a security interest or lien holder to satisfy a lien on a vehicle, requiring information about the lien holder, vehicle owner, and vehicle identified by year, make, VIN, and title details. The lien holder signs the affidavit under penalty of perjury and it must be notarized, then attached to an application for a certificate of title.

    Copyright:

    © All Rights Reserved
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    of 1

    PRINT CLEAR

    Form T-4
    (Rev. 12-2013)

    NOTICE OF SATISFACTION OF SECURITY INTEREST OR LIEN HOLDER’S AFFIDAVIT

    Instructions: This Affidavit should be executed by the person who holds a security interest or lien on the motor vehicle
    described below, pursuant to Article 3 of Chapter 3 in Title 40. Except for signatures, type or print legibly in black or
    blue ink or complete electronically and print.
    Note: This form is not permitted for use by any participant in the Electronic Lien on Title (ELT) for any security interest
    or lien which has been recorded electronically.

    Personally appearing before the undersigned officer, duly authorized by law to administer oaths, comes

    _____________________________________________________________________________________, of
    Printed Full Legal Name of Sole Proprietor/Partner or Executive Officer and Driver’s License Number

    _____________________________________________________________________________________, located at
    Legal Business Name of Security Interest or Lien Holder as listed on Certificate of Title

    _____________________________________________________________________________________.
    Business address, including city, state and zip code

    __________________________________________________________________________________________________
    Owner(s) names as it appears on Certificate of Title
    __________________________________________________________________________________________________

    __________________________________________________________________________________________________
    Residence address, including city, state and zip code
    Vehicle Year & Make: Vehicle Identification Number: Model & Body Style:

    State of Title Records: Title number: Account number:

    I understand that, pursuant to the Motor Vehicles Certificate of Title Act, the State Revenue Commissioner has the authority to □ Yes
    investigate issues surrounding the titling and registration of motor vehicles and may refuse to issue a certificate of title if there are
    reasonable grounds to believe that the application contains a false statement or the applicant fails to furnish required information or
    documents or any additional information the commissioner reasonably requires. I understand that the Department may have
    information as to the vehicle’s title history, the security interest holder’s or the owner’s address, or some other information that is
    relevant to the Act’s requirements, which lien holder does not have. I understand that, based upon this information, the Department
    has the discretion to reject the application for title.
    Notary Public Acknowledgement
    I am over the age of majority and give this affidavit on the basis of my personal knowledge of facts and circumstances surrounding the security
    interest or lien related to the motor vehicle listed:

    __________________________________________________________________________________________________
    Sole Proprietor/Partner or Executive Officer Signature Date

    Notary Public residence address including City, State and Zip Code
    Sworn to and subscribed before me this __________ of
    (Day)
    _____________________________, ____________
    (Month) (Year)
    Notary Public’s Signature & Notary Seal or Stamp Notary Public’s Printed Name

    Date Notary Commission Expires: Notary Public business phone number

    This form must be legibly completed and attached to the application for Certificate of Title.
    Any alteration or correction voids this form.
    All previous revisions of this form are obsolete.

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