STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS
DIVISION OF MOTOR VEHICLES
RESEARCH/TITLE OFFICE
600 New London Avenue
Cranston, RI 02920-3024
Fax: 401-462-5783
Phone: 401-462-4368
AFFIDAVIT AND ASSIGNMENT OF TITLE – SOLE HEIR AFFIDAVIT
Now come(s) the undersigned, averring under penalty of perjury that ___________________________________
NAME OF DECEDENT
passed away on _________________.
DATE OF DEATH
That under the laws of the State of Rhode Island (I/We) am/are the sole heir(s) of the decedent. That no letters
testamentary or letters of administration upon the estate of the decedent have been issued, and that no petition
therefore is pending.
And further state there are no liens or encumbrances on the motor vehicle described as a:
__________
____________________
_________________________
YEAR
MAKE
VEHICLE IDENTIFICATION NUMBER (VIN)
And hereby assign and warrant title to this vehicle to:
Purchaser’s printed name:
______________________________________________
Residence Address:
___________________________________________________________
Purchaser’s signature:
______________________________________________
Federal and State laws require that you state the mileage upon transfer of ownership and failure to complete or
providing a false statement may result in fines and/or imprisonment.
(I/We) certify the odometer reads _____________ (no tenths) miles and to the best of my knowledge reflects the
actual mileage of the vehicle unless one of the following statements is checked:
1. The mileage state is in excess of its mechanical limits.
2. The odometer reading is not the actual mileage. Warning - Odometer Discrepancy.
Signature of heirs:
Relationship to Decedent:
______________________________________
______________________________________
______________________________________
______________________________________
______________________________________
______________________________________
I, THE UNDERSIGNED, HEREBY MAKE APPLICATION FOR ASSIGNMENT OF TITLE (SOLE HEIR AFFIDAVIT), AND DECLARE UNDER
PENALTY OF PERJURY THAT ALL STATEMENTS MADE ON THIS APPLICATION ARE TRUE AND COMPLETE TO THE BEST OF MY
KNOWLEDGE AND BELIEF.
PERSONAL INFORMATION CONTAINED IN YOUR MOTOR VEHICLE RECORD WILL BE DISCLOSED ONLY IF THE STATE HAS
OBTAINED THE EXPRESS CONSENT OF THE PERSON TO WHOM SUCH PERSONAL INFORMATION PERTAINS.
□
□
DO YOU CONSENT TO SUCH DISCLOSURE?
YES
NO
Subscribed and sworn to me this ______ day of _________________________, 20_____.
______________________________________
______________________________________
SIGNATURE OF NOTARY PUBLIC
COMMISION EXPIRATION DATE (mandatory)
CERTIFIED COPY OF DEATH CERTIFICATE REQUIRED WITH THIS DOCUMENT
rev. 12/11