Form Vsd 775.1 - Unable To Locate Beneficiary Affidavit

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Secretary of State
This space for use by
Secretary of State.
Unable to Locate Beneficiary ffidavit
Secretary of State
Vehicle Services Department
This form must be used by the estate
Titles Division
501 S. Second St.
upon the death of a vehicle owner
Springfield, IL 62756
when unable to locate the beneficiary.
217-785-3000
Description of Vehicle:
Year: _________________ Make: __________________ Model: ___________________ Body Type: __________________
Vehicle Identification Number:
The undersigned hereby affirms that:
1. The estate of the deceased and sole owner of the aforementioned vehicle has exhausted all resources in locating the
named beneficiary on Illinois Title Number: _______________________________________________________________
Beneficiary’s name and last known address:
_________________________________________________________________________________________________
Name
_________________________________________________________________________________________________
Address (Street, City, State, ZIP)
2. A notice was sent by certified mail 30 days before the sale of the aforementioned vehicle to the last known address of the
named beneficiary.
3. The estate of the deceased is required to post a notice in an effort to locate the beneficiary of the above-described vehicle.
Notice was published once a week for three consecutive weeks in ___________________________________, which is a
newspaper circulated in _____________________________________ Illinois, which is in a county where the estate is
being probated, as required by Illinois law.
4. The above vehicle will be sold. The vehicle will be purchased by:
Purchaser’s Printed Name(s):___________________________________________________________________________
Purchaser’s Address: _________________________________________________________________________________
Federal and state law requires that you record the mileage in connection with the transfer of ownership. Failure to complete
this requirement or providing a false statement may result in fines and/or imprisonment.
I certify to the best of my knowledge that the odometer reading is the actual mileage of the vehicle, unless one the
following statements is checked:
Odometer _______________________
1. The mileage stated is in excess of its mechanical limits.
No Tenths
_______________________________
2. The odometer reading is not the actual mileage.
_______________________________
“WARNING — ODOMETER DISCREPANCY”
The undersigned states that all requirements set forth concerning the search for the beneficiary, and the undersigned
will assume all liability and costs for any litigation that may arise from the sale of this vehicle.
________________________________________________ ________________________________________________
Signature of Seller
Signature of Purchaser
________________________________________________ ________________________________________________
Printed Name of Seller
Name of Purchaser
________________________________________________ ________________________________________________
Address of Seller
Date of Sale/Odometer Disclosure
Subscribed and sworn to before me this ____________day of _______________________________20 ______ .
Notary Public Signature: _______________________________________ Date ________________________________
Printed by authority of the State of Illinois. May 2013 — 1 — VSD 775.1

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