Form Tc-569c - Survivorship Affidavit

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Utah State Tax Commission
TC-569C
Survivorship Affidavit
Rev. 1/13
Get forms online - tax.utah.gov
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
Make
Model
Year
Body type
Vehicle/Hull Identification Number (VIN/HIN)
License plate number
Watercraft length
State last registered
Trailer length
ft________ in________
ft________ in________
Section 2 - Deceased Owner Information
Deceased owner’s name
City and state where death occurred
Date of death
Section 3 - Survivor Information and Signature
Survivor’s name
Survivor’s address (includes street, city, state, and ZIP)
Subscribed and sworn to before me on
Pursuant to Utah Code 75-3-1201, I hereby transfer the Certificate of Title issued for the
vehicle identified on this statement to the new owner shown below. I certify that the decedent
this _____ day of _________________ 20____
left not more than four boats, motor vehicles, trailers, or semi-trailers, and that 30 days have
by __________________________________________
elapsed since the death of the decedent. No appointment of a personal representative has
been granted or is pending. The value of the entire estate subject to administration wherever
Place notary stamp in space below
located, excluding the boats, motor vehicles, trailers, or semi-trailers, less liens and
encumbrances, does not exceed $100,000. I further certify that I am entitled to the vehicle and
that this transfer will not prejudice the creditors of the decedent.
Signature of affidavit (survivor)
Notary signature
Date
Date
X
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)
State
City
ZIP code

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