STATE OF CONNECTICUT

1 STATE OF CONNECTICUT Motor Vehicle and vessel gift declaration I, _____ the undersigned (donor), residing at Donor s name (print) _____, STATE that: Street address City STATE on or about _____, I transferred ownership and title of a Date Motor Vehicle or vessel _____ Motor Vehicle or Hull Identification Number (VIN or HIN) _____ _____ _____ Year Make Model to _____ (donee), Donee s name (print) receiving no compensation in return, in either cash, property or personal services; There has been neither a promise to pay for said vehicle or vessel nor any expectation of any future compensation in either cash, property or personal services from the donee; and The donee has not assumed payment of any chattel mortgage or conditional bill of sale on the vehicle or vessel described above.

2 I declare under penalties of false statement that I have examined this information and to the best of my knowledge and belief it is true, complete, and correct. (The penalty for false statement is imprisonment not to exceed one year or a fine not to exceed two thousand dollars, or both.) Donor: Print donor name Donor signature Date Donee: Print donee name Donee signature Date AU-463 (Rev. 12/2012)