AFFIDAVIT OF OWNERSHIP BY REPOSSESSION

1 Revised 9/2020 I being duly sworn deposes and say that Representative of Secured Party is/are the lawful owner(s) of the following Secured Party described motor vehicle/motorboat due to REPOSSESSION . Year Make Model Vehicle Identification Number/Hull Identification Number I further depose that: debtor has defaulted in connection with an obligation secured by the vehicle/boatspecified above; have exercised our post-default remedies with respect to this collateral; reason of this exercise, we are acquiring the rights of the debtor in this from Name of Debtor City State Zip AddressAffiant swears that he/she is making this statement for the purpose of having the designated County Official issue a Certificate of Title in his/her name as indicated by the attached Application for Certificate of Title.

2 Affiant swears that he/she will warrant and defend the titl e and rights of this motor vehicle and protect the issuing designated County Official from any damages that might arise from irregularities on same. Signature of Representative of Secured Party Printed Name of Representative of Secured Party Subscribed and Sworn to before me this day of , Notary Public Seal The lien shall not be released on the face of the title accompanying this AFFIDAVIT . The date of Transfer of OWNERSHIP recorded above must be equal to or less than the notary date. The date of Transfer of OWNERSHIP will be used as the purchase date on the Certificate of Titleissued pursuant to this OF OWNERSHIP BY REPOSSESSION This form is for Nebraska lienholders only.

3 Out-of-state lienholders must use a form approved by their state of residence. Date of Original Contract Date of Transfer of OWNERSHIP