MVR-58 (Rev. 10/16) North Carolina Division of Motor Vehicles ... - NCDOT

MVR-58 (Rev. 10/16)

North Carolina Division of Motor Vehicles

AFFIDAVIT OF FACTS FOR THE REGISTRATION OF A MOPED

North Carolina General Statute 20-4.01 (27)(D1) defines a moped as, "A vehicle, other than a motor-driven bicycle or electric assisted bicycle, that has two or three wheels, no external shifting device, and a motor that does not exceed 50 cubic centimeters piston displacement and cannot propel the vehicle at a speed greater than 30 miles per hour on a level surface. The motor may be powered by electricity, alternative fuel, motor fuel or a combination of each."

Instructions: The following questions must be answered in detail and this form must be presented as an application for the registration of a moped for which a Manufacturer's Certificate of Origin cannot be furnished. Furnish any documents in your possession that will show proof of ownership. Examples include titles, bill of sale, conditional sales contract, invoices, or out of state registrations.

A valid North Carolina Driver License or North Carolina ID Card must be presented when applying for registration.

YEAR

MAKE

OWNER 1 ID #

VEHICLE SECTION BODY STYLE VEHICLE IDENTIFICATION NUMBER*

MOPED FULL LEGAL NAME OF OWNER

OWNER SECTION

OWNER 2 ID #

FULL LEGAL NAME OF OWNER

STREET ADDRESS

CITY

STATE

ZIP CODE

COUNTY

MAILING ADDRESS IF DIFFERENT FROM ABOVE

VEHICLE LOCATION IF DIFFERENT FROM ABOVE

I certify for the moped described above that I have financial responsibility as required by law.

__________________________________________________________________ Insurance company authorized in N.C

_____________________________________________ Policy Number

1. I attest to the following: (Must Initial) (a) This vehicle has two or three wheels, no external shifting device and a motor that does not exceed 50 cubic centimeters piston displacement. ____________(owner's initials) (b) This vehicle cannot propel at a speed greater than 30 miles per hour on a level surface. ______________ (owner's initials)

2. I am the true and legal owner of the above described moped. I acquired the vehicle on or about __________________, 20 ___________

3. From whom did you purchase this vehicle? (check one): Private Party (Individual) - Name ___________________________________ Address ________________________________________

Business - Name __________________________________________ Address ______________________________________________

4. I do not have a Manufacturer's Certificate of Origin because (check one): One was not provided to me by the dealer at the time of purchase; or Moped was purchased used from individual Other (explain): _______________________________________________________________________________________________

I affirm under penalty of perjury and/or punishment pursuant to N.C.G.S. 20-112, that the foregoing information is based upon my personal knowledge and is true and accurate to the best of my knowledge.

Signature of Owner(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 voluntarily signed the foregoing document for the purpose stated herein and in the capacity indicated:

___________________________________________________________________________________________(name(s) of principal(s) ).

Notary

Notary Printed

Signature _______________________________________________ or Typed Name _________________________________________

(SEAL)

My Commission Expires ____________________________________

*If the VIN cannot be located, you will need to contact your local NCDMV License & Theft Inspector.

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