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SELLER’S AFFIDAVIT

Type or Print in Blue or Black Ink Only

Any Alteration Will Void This Form

STATE OF WEST VIRGINIA

COUNTY OF DATE OF SALE

THIS IS TO CERTIFY THAT I:

SELLER’S NAME
STREET ADDRESS	First Middle Initial Last
CITY
City State Zip Code (IF SELLER IS NOT A W.VA. RESIDENT, A DISCLAIMER FROM SELLER’S STATE DMV MUST BE ATTACHED STATING THAT THERE IS NO PREVIOUS TITLE FOR THE VESSEL/VEHICLE.)

Check Appropriate Box, Then Complete Appropriate Section (A or B) Below

AM THE SOLE OWNER OF A: VEHICLE TRAILER MOTORBOAT

SECTION A: VEHICLE OR TRAILER INFORMATION
YEAR		MAKE					BODY STYLE
VIN NUMBER (SERIAL NUMBER)
SECTION B: MOTORBOAT INFORMATION
YEAR	MAKE			LENGTH				MODEL
MFR’s HIN (SERIAL NUMBER)
MAKE OF MOTOR(S)						HORSEPOWER
MOTOR SERIAL NUMBER
HOW, WHEN AND FROM WHOM WAS THE ABOVE ACQUIRED?
PURCHASER’S NAME
				(Please Print)
PURCHASE PRICE:
Vehicle			Boat		Motor				Trailer

TO THE BEST OF MY KNOWLEDGE, THERE IS NOT OUTSTANDING CERTIFICATE OF TITLE OR
REGISTRATION FOR THE VESSEL/VEHICLE LISTED ABOVE, THERE ARE NO LIENS OR ENCUMBRANCES AGAINST IT, AND I

Seller’s Name

WILL ASSUME FULL RESPONSIBILITY FOR ISSUANCE OF A WEST VIRGINIA CERTIFICATE OF TITLE.

SELLER’S SIGNATURE (X)

SWORN TO BEFORE ME AND SUBSCRIBED IN MY PRESENCE THIS

DAY OF , 19 ,

Notary Public My Commission Expires Year

Note * This affidavit must be accompanied by a serial number certification completed by any law enforcement officer.

* If a title or registration does exist, then this affidavit will not be accepted.