PDF Nebraska Department of Motor Vehicles

PURCHASER'S AFFIDAVIT

Application for title for the following described motor vehicle or trailer is being made:

(Year)

(Make)

(VIN)

The undersigned, being duly sworn, depose or affirm that the following is true about the abovedescribed motor vehicle or trailer:

This motor vehicle or trailer was purchased from

on

Name of Last Seller

.

Date of Purchase

Certificate of Title #

Title Number

which was originally assigned

to

Name(s) of Purchaser

has been lost or mutilated.

The undersigned has requested that the above-named dealership make application for a new original certificate of title for the purposes of assigning ownership.

DATED this

day of

,

.

Subscribed and sworn to before me this

day of

Signature of Last Selling Dealer

,

(Notary Public or Designated County Official)

This completed, signed and notarized affidavit is required to be submitted by a licensed motor vehicle or trailer dealer with an Application for Certificate of Title and photocopy from the dealer's records of the front and back of the lost or mutilated original certificate of title which was assigned to the dealer showing a reassignment to the above Purchaser.

Filing of a false affidavit violates the provisions of the Motor Vehicle Registration Act. Any person, firm, association, partnership, Limited Liability Company or corporation that does so may be subject to prosecution.

3/2022

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