Transcription of North Carolina Division of Motor Vehicles AFFIDAVIT OF …
1 Seller/s_____(NAME/S AND ADDRESS)This will certify that I/we did not sell or deliver a _____(YEAR)(MAKE)(BODY STYLE)_____to _____ .( vehicle IDENTIFICATION NUMBER)(PURCHASER/S)I/we did sell and deliver a _____(YEAR)(MAKE)(BODY STYLE)( vehicle IDENTIFICATION NUMBER)The incorrect manufacturer s certificate of origin or the incorrect certificate of title number _____ was (SIGNATURE/S OF SELLER/S)By: _____(AUTHORIZED REPRESENTATIVE)Date _____County _____State_____I certify that the following person(s) personally appeared before me this day, each acknowledging to me that he or she voluntarilysigned the foregoing document for the purpose stated therein and in the capacity indicated: _____ (NAME(S) OF PRINCIPAL(S))NotaryNotary PrintedSignature_____or Typed Name _____(SEAL)My Commission Expires _____Purchaser/s_____(NAME/S AND ADDRESS)This will certify that I/we did not purchase or take delivery of _____(YEAR)(MAKE)(BODY STYLE)_____from _____ .( vehicle IDENTIFICATION NUMBER)(SELLER S NAME/S)I/we did purchase and take delivery of _____(YEAR)(MAKE)(BODY STYLE)( vehicle IDENTIFICATION NUMBER)The incorrect manufacturer s certificate of origin or the incorrect certificate of title number _____ was (SIGNATURE/S OF PURCHASER/S)Date _____County _____State_____I certify that the following person(s) personally appeared before me this day, each acknowledging to me that he or she voluntarilysigned the foregoing document for the purpose stated therein and in the capacity indicated.
2 _____ (NAME(S) OF PRINCIPAL(S))NotaryNotary PrintedSignature_____or Typed Name _____(SEAL)My Commission Expires _____Lienholder _____(NAME AND ADDRESS)This will certify that we hold no interest whatsoever in a _____(YEAR)(MAKE)(BODY STYLE)_____ for which the manufacturer s certificate of origin or certificate of title number _____( vehicle IDENTIFICATION NUMBER)was assigned in error to _____We do hold a security agreement on a _____(YEAR)(MAKE)(BODY STYLE)( vehicle IDENTIFICATION NUMBER)_____(LIENHOLDER)By: _____(AUTHORIZED REPRESENTATIVE)Date _____County _____State_____I certify that the following person(s) personally appeared before me this day, each acknowledging to me that he or she voluntarilysigned the foregoing document for the purpose stated therein and in the capacity indicated: _____ (NAME(S) OF PRINCIPAL(S))NotaryNotary PrintedSignature_____or Typed Name _____(SEAL)My Commission Expires _____North Carolina Division of Motor VehiclesAFFIDAVIT OF FACTS SURROUNDING THE INCORRECT ASSIGNMENT OF AMANUFACTURER S CERTIFICATE OF ORIGIN OR A CERTIFICATE OF TITLEMVR-28 (Rev.)
3 1/06)123
