BUY HERE – PAY HERE DEALER AFFIDAVIT PURCHASER’S ...
DMV-86-TR Rev. 11/2022
STATE OF WEST VIRGNIA DEPARTMENT OF TRANSPORTATION
DIVISION OF MOTOR VEHICLES
BUY HERE ? PAY HERE DEALER AFFIDAVIT
PURCHASER'S INFORMATION
____________________________________ _____________________________________ _________________
(Purchaser's Name)
(Purchaser's Address)
(Phone #)
____________________________________ _____________________________________ _________________
(Co-Purchaser's Name)
(CO-Purchaser's Address)
(Phone #)
VEHICLE DESCRIPTION:
Make
Year
Body Type
Vehicle Identification Number
LIEN INFORMATION:
Name of Lienholder ____________________________________________________________________________
Address ______________________________________________________________________________________
Date of Sale _________________________
Lender Code
Total Amount of Lien
Kind of Lien
Date
Total Amount of Payments
Amount of Payment
Payment Due Date
DEALER INFORMATION:
Name of Dealership _____________________________________ Dealer Number __________________________
Address ______________________________________________________________________________________
The Purchaser (s) do hereby acknowledge purchase of the vehicle described above and that the listed lienholder has a valid lien on the vehicle.
X ____________________________ _____________ ________________________________ ____________
Purchaser's Signature
Date
C-Purchaser's Signature
Date
___________________________________ __________
Dealer Representative's Signature
Date
White Copy ? Submit with original title work Pink Copy ? Dealer Yellow Copy - Customer
................
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