Form T-227 - One And The Same Affidavit Refer To Additional Information On Back

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Form T-227 (Rev. 05-2005)
One And The Same Affidavit
WEB & MVD Manual
Refer to Additional Information on Back
Form Use
To document and take responsibility for any differences or conflicts in a legal name, signature or assignments of title
(First name, middle name or initials. Suffixes under certain conditions, i.e., Jr., Sr., III, IV, II, etc.).
All requested information (except for signatures) must be electronically completed and printed; legibly printed by
hand; or, typed.
Form can be used with an application for title supported by a replacement title application; Georgia Title; Statement
of Origin; out-of-state title assigned to a Georgia owner; or, Georgia court order or judgment.
Form can not be used to explain differences in a motor vehicle dealer’s name.
Form can not be used in place of a divorce decree; marriage certificate or court ordered name change.
PART 1
(Electronically Complete/Print, Type, or Legibly Print by Hand)
This affidavit is given to secure a title in the name of_______________________________________________________
for the following vehicle
____________
_________________________________
Vehicle Year
Vehicle Make
Vehicle Identification Number
________________________________________________________
PART 2
(Electronically Complete/Print, Type, or Legibly Print by Hand)
This is to certify that _______________________________________________________________________________
and ___________________________________________________________________ are one and the same person or
company.
This is to further certify that I, (We)___________________________________________________________
of ______________________________________________________________(Company/Business Name, if applicable)
shall hold harmless, pay restitution and indemnify: the State of Georgia, the Department of Revenue, Motor Vehicle
Vehicle Division , their agents, the motor vehicle’s owner(s) and the motor vehicle’s security interest holder(s) or lien
holder(s) for any and all losses or incurred costs, should it be alleged and proved or alleged and adjudicated that this
affidavit contains false, fraudulent, incorrect, misleading or erroneous information.
PART 3
_____________________________________________
_______________________________________________
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 4
Notary Public’s Acknowledgement
Sworn to and subscribed before me this _____________ day of ______________________________, __________.
_____________________________________________
______________________________, ___________.
Signature & Seal 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

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