Fillable Form Pwd 778 - Pawn Shop Affidavit printable pdf download

Pawn Shop Affidavit (PWD 778)

This form is used when a vessel and/or outboard motor has been left as unredeemed pledged goods at a

pawn shop. The pawn shop is required to title the vessel and/or outboard motor in the pawn shop's name,

prior to selling (unless it is a licensed Marine Dealer). Supporting documents, original signatures and

payment for fees must accompany this form for processing.

Boat Information: TX _____________ HIN (Serial #) _________________________________

Make____________________________ Year___________

Outboard Motor Information: TX__________________ MIN (Serial #) ___________________________

Make ____________________________Year___________

Pawn Shop Name:

_________________________________________________________

Pawn Shop Address:

_________________________________________________________

Pawn Shop Phone:

_________________________________________________________

We, the above named Pawn Shop, have complied with the requirements under “Unredeemed Pledged

Goods” of chapter 371.169 of the Texas Finance Code.

Pawn Ticket Number _________________________________

Dated ______________________

Pledgor Name

_______________________________________________________________

Pledgor Address

_______________________________________________________________

The above named vessel and/or outboard motor has been pulled as “Unredeemed Merchandise”.

WARNING: Falsifying information on documents is a punishable offense. Texas Penal Code Chapter 37 Section 37.10

Any person who knowingly makes a false entry in, or false alteration of a governmental record is guilty of a felony of the

third degree punishable by confinement in jail for any term of not more than 10 years or less than 2 years and punished by

a fine not to exceed $10,000.

I HEREBY CERTIFY THAT ALL STATEMENTS IN THIS DOCUMENT ARE TRUE AND CORRECT TO THE BEST OF MY

KNOWLEDGE AND BELIEF.

Pawn Shop Representative Signature: _________________________________________________

Subscribed and sworn before me this ___________ day of __________________ , _____________

Month

Year

___________________________ _____________________ , Texas

Notary Public

County

Commission Expires_________________________________

Texas Parks and Wildlife Department maintains the information collected through this form. With few exceptions, you are entitled to be informed about the information we

collect. Under Sections 552.021 and 552.023 of the Texas Government Code, you are also entitled to receive and review the information. Under Section 559.004, you

are also entitled to have this information corrected.

PWD 778 - A0900 (11/10) Texas Parks and Wildlife Department • 4200 Smith School Road, Austin, TX 78744 •