TC-569B Repossession Statement Rev. 12/12 - Utah
Utah State Tax Commission
Repossession Statement
Clear form
TC-569B Rev. 12/12
Division of Motor Vehicles ? PO Box 30412, Salt Lake City, UT 84130 ? Telephone 801-297-7780 or 1-800-368-8824
Section 1 - Vehicle Information
Year
Make
Model
Vehicle/Hull Identification Number (VIN/HIN)
Get forms online - tax. Body type
License plate number
State last registered
Section 2 - Owner Information Primary owner's name (last, first, middle initial, or business name)
Trailer length ft________ in________
Watercraft length ft________ in________
Co-owner's name (if at different street address, check here and list on back)
Street address (primary owner)
City
State ZIP code
Mailing address, if different from Street Address (primary owner)
City
State ZIP code
Section 3 - Repossession Information and Signature Recorded lien holder
Street address
City
Date repossessed State ZIP Code
Under penalties of perjury, I declare that I am the recorded lien holder or am an authorized agent for the recorded lien holder for the above-described vehicle and that I did lawfully repossess the vehicle under default, based on the conditions of the original agreement. I certify that the above-described vehicle was repossessed from the person or company named on this statement and that I delivered and conveyed all rights, title, and interest to the new owner named below. I agree to indemnify the Utah State Tax Commission and all persons acting under their direction from any and all liability and shall defend all litigation that may arise as a result of the issuance of a new Certificate of Title on the above-described vehicle."
Repossessor's signature
Date
X
Section 4 - New Owner Information Primary owner's name (last, first, middle initial, or business name)
Co-owner's name (if at different street address, check here and list on back)
Street address (primary owner)
City
State ZIP code
Mailing address, if different from Street Address (primary owner)
City
State ZIP code
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