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Certificate of Fact

Use this form to make a statement of fact.

License plate/Registration number Year

Make

Series/Body style

Vehicle Identification Number (VIN) or Vessel Hull Identification Number (HIN)

I certify that

I certify under penalty of perjury under the laws of the state of Washington that the foregoing is true and correct.

Date and place

X When completed, print this out and sign here.

Signature

Notarization/Certification

State of Signed or attested before me on

, County of by

(Seal or stamp)

Signature

Printed or stamped name Title

and Dealer or county/office number or notary expiration date

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TD-420-043 (R/8/11)WA

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