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    Ownership Statement: Clear Form

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    smshep2014
    Public insufficient evidence of ownership packet form tc-569a

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Ownership Statement: Clear Form

    Uploaded by

    smshep2014
    5 views1 page
    Public insufficient evidence of ownership packet form tc-569a

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    tc-569a

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    © © All Rights Reserved

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    Public insufficient evidence of ownership packet form tc-569a

    Copyright:

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

    Ownership Statement: Clear Form

    Uploaded by

    smshep2014
    Public insufficient evidence of ownership packet form tc-569a

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 1

    Utah State Tax Commission Clear form

    TC-569A
    Ownership Statement Rev. 1/13

    Division of Motor Vehicles · PO Box 30412, Salt Lake City, UT 84130 · Telephone 801-297-7780 or 1-800-368-8824 Get forms online - tax.utah.gov

    Section 1 - Vehicle Information


    Year Make Model Vehicle/Hull Identification Number (VIN/HIN) Body type

    License plate number State last registered Trailer length Watercraft length
    ft________ in________ ft________ in________

    Section 2 - Owner Information


    Primary owner’s name (last, first, middle initial, or business name) Co-owner’s name (if at different street address, check here and list on back)

    Street address (primary owner) City State ZIP code

    Mailing address, if different from Street Address (primary owner) City State ZIP code

    Section 3 - Facts and Indemnification Agreement


    Value of vehicle Purchase price Date of purchase
    $ $
    If the fair market value of the vehicle exceeds $1,000, a surety bond may be required, not to exceed twice the fair market value of the
    vehicle. This value may be reassessed by the Division during the application process.
    Explain why outstanding certificate of title was not obtained or why the attached certificate of title is not valid. Explain in detail how, where, and
    when you acquired the vehicle, who was involved, the condition of the vehicle, and any other information regarding the vehicle.

    Under penalties of perjury, I declare that to the best of my knowledge and belief, this statement is true, correct, and complete. I further state that to the best
    of my knowledge, the vehicle is free and clear of any liens, encumbrances, lawful claims, demands of any person, and is not involved in any existing or
    pending litigation. I agree to indemnify the Utah State Tax Commission and all persons acting under direction of the Commission, from any and all liability
    and shall defend all litigation that may arise as a result of the issuance of a certificate of title in my name.
    Signature of applicant Date
    X

    For Office Use Only


    NCIC Check

    No Hit Found Hit Found Partial Hit Found

    Officer/Agent name Agency name

    ID/Badge number Date

    NLETS Search

    10 - State 50 - State No Record Found Record found in: ______________________________________________

    Officer/Agent name Agency name

    ID/Badge number Date

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