Form Ps2017-10 - Notification Of Assignment, Release Or Grant Of Secured Interest

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MINNESOTA DEPARTMENT OF PUBLIC SAFETY
Print Form
DRIVER AND VEHICLE SERVICES
445 Minnesota Street
Saint Paul, MN 55101-5187
Phone: (651) 297-2126
Web: dvs.dps.mn.gov
N otifica tion of Ass ignm ent , R ele ase or Grant of Se cur e d Int e rest
(Instructions on reverse side)
YEAR
MAKE
TYPE
MODEL
VEHICLE IDENTIFICATION NUMBER
TITLE NUMBER
OWNER(S) NAME
SECURED PARTY’S NAME
STREET ADDRESS
STREET ADDRESS
A
CITY
ZIP CODE
STATE
CITY
STATE
ZIP CODE
SIGNATURE OF OWNER(S), NECESSARY ONLY WITH GRANT
SIGNATURE AND TITLE OF AUTHORIZED AGENT
X
X
The secured party named in Section A has assigned his interest to the secured
--- NOTICE ---
ASSIGNMENT
party named in Section B.
This form must be notarized
The secured party named in Section A no longer claims a security interest in the
to release a lien.
RELEASE
vehicle described above. Date of Release
Subscribed and sworn to before me
The owner(s) have granted to the secured party named in Section A, a security
interest in the vehicle described above.
GRANT
this
Date of Security Agreement
day of
20
ASSIGNEE’S NAME, NECESSARY ONLY WITH ASSIGNMENT
NOTARY PUBLIC
B
STREET ADDRESS
COUNTY
STATE
ZIP CODE
CITY
MY COMMISSION EXPIRES
PS2017-10 (6/11)
- over -

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