For a Vehicle, Watercraft, or Mobile Home

Michigan Department of State

APPOINTMENT OF AGENT

Clear Form

For a Vehicle, Watercraft, or Mobile Home

NOTE: This form CANNOT be used for either of the following:

? To apply for an instant title, unless the Agent is a licensed vehicle dealer.

? To appoint an Agent who would be signing a title, or application for title,

as both the buyer and seller of a vehicle, watercraft, or mobile home.

All Information must be completed in ink.

I appoint ___________________________________________________

(agent¡¯s name)

Agent¡¯s address: ____________________________________________

____________________________________________

Agent¡¯s Driver License

Number or ID Card Number: ______________________________________

as my agent to sign my name to legal documents pertaining to the sale, purchase

or titling of the unit described below as required by Michigan law. I am voluntarily

making this appointment and am aware that I may bear responsibility for any

information provided by, or actions taken by my agent.

Year

VIN

Make

License Plate Number (if any)

Vehicle, Watercraft, or Mobile Home Owner Information

Owner¡¯s Name

Owner¡¯s Street Address

State

City

Zip Code

Owner¡¯s Driver License or ID Card Number

Daytime Phone Number

Today¡¯s Date

A false statement in connection with a title transaction is a crime.

NOTE: Owner must provide a photocopy of their valid driver's license

or state ID card with this form. Agent will present this completed form

and required photocopy to the Secretary of State branch.

Owner¡¯s Signature:

X

Authorities granted under Public Acts 300 of 1949, 451 of 1994, and 96 of 1987, as amended. TR-128

(05/24)

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