Form Mv-13a - Affidavit To Support A Request For Correction Of A Georgia Certificate Of Title

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MV-18A Affidavit (Rev. 0 3 -20 13 )
AFFIDAVIT TO SUPPORT A REQUEST FOR CORRECTION OF A GEORGIA CERTIFICATE OF TITLE
PART 1
Except for signatures, type, print legibly in black or blue ink or complete electronically and print.
Personally appearing before the undersigned officer, duly authorized by law to administer oaths, comes
____________________________________________, who deposes and states under oath the following:
(Full Legal Name)
1.
I am over the age of majority and give this affidavit on the basis of my personal knowledge of facts and
circumstances surrounding Georgia Certificate of Title number____________________________ (“Certificate”); and
2.
I am the owner of the motor vehicle identified on the Certificate, the accompanying application for title and other
documents; and
3.
The following information that was based on the documents submitted for its issuance and recorded on the
Certificate is incorrect. The correct information is also indicated below.
INCORRECT INFORMATION
CORRECT INFORMATION
Vehicle Identification No. (VIN)
___________________________
_____________________________
Vehicle Make
___________________________
_____________________________
Year Model
___________________________
_____________________________
No. of Cylinders
___________________________
_____________________________
Body Style
___________________________
_____________________________
New or Used
___________________________
_____________________________
Owner(s) Name(s)
___________________________
_____________________________
Brand/Legend (Not related to odometer)
___________________________
_____________________________
I understand that microfilm /imaged copies of the documents that should be used to issue a Certificate are no longer availabl e
and that the Department is issuing a Certificate based on the information provided in this affidavit, the accompanying
application for title and other documents submitted with this affidavit. Therefore, I agree to defend, indemnify and hold
harmless, the State of Georgia, Department of Revenue, Motor Vehicle Division, County Tag Agents, their commissioners,
directors, officers, and employees, from and against any and all claims, demands, liabilities, losses, costs or expenses,
including attorneys’ fees, due to liability to a third party or parties, for any loss due to any injury arising out of or resulting
from t he Department’s issuance of a Certificate based on the information contained in either this affidavit, the
accompanying application for title or any other documents submitted with this affidavit.
PART 2
_____________________________________________
_______________________________________________
Signature of Person Completing Affidavit
Driver’s License # of Person Completing Affidavit
_____________________________________________
_______________________________________________
Street Address of Person Completing Affidavit
Printed Company/Business Name (if Applicable)
_____________________________________________
_______________________________________________
City, State, Zip of Person Completing Affidavit
Position with Company/Business (if Applicable)
____________________________________________
_______________________________________________
Telephone # of Person Completing Affidavit
Company/Business Address (if Applicable)
PART 3
Notary Public’s Acknowledgement
Sworn to and subscribed before me this _____________ day of ______________________________, __________.
( Year )
( Month )
_____________________________________________
______________________________, ___________.
Signature & Seal or Stamp of Notary Public
Date My Commission Expires
_____________________________________________
__________________________________________
Printed Name of Notary Public
Driver’s License # of Notary Public
_____________________________________________
__________________________________________
Street Address of Notary Public
City, State, Zip Code & Telephone # of Notary Public
Refer to Form MV-18A Instructions for additional information and requirements

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