Form Tc-569 - Combined Affidavit printable pdf download

Form Tc-569 - Combined Affidavit

Utah State Tax Commission

Combined Affidavit

TC-569

Rev. 6/00

Facts and Indemnification Agreement, Repossessions and Bill of Sale, Survivorship

Division of Motor Vehicles - 210 N 1950 W, Salt Lake City, Utah 84134 - (801) 297-7780

Vehicle Information

VIN

Year

Make

Model

Body style

State last registered

License number

Odometer reading (no tenths)

Utah certificate of title number

Check only one box

I certify that to the best of my knowledge the odometer reading reflects the actual mileage.

I certify that to the best of my knowledge the odometer reading reflects the amount of mileage in excess of its mechanical limits.

I certify that the odometer reading is not the actual mileage.

Warning - odometer discrepancy

Name of applicant

Date of vehicle possession

Address (include street, city, state, and ZIP code)

Facts and Indemnification Agreement

Name of person or company from whom the vehicle was acquired

Address (include street, city, state, and ZIP code)

Value of vehicle

Explain why outstanding certification of title was not obtained or why the attached title is not negotiable. Explain in

detail how and why you acquired the vehicle, who was involved, when did you acquire the vehicle, etc. If the fair

market value of the vehicle exceed $1,000, a surety bond may be required, not to exceed twice the fair market value

of the vehicle.

Warning: Fraudulent application and falsification of documents is a felony under Utah Law.

Under penalties of perjury, I declare that to the best of my knowledge and belief, this agreement is true, correct, and complete. I further state that to the

best of my knowledge, the vehicle is free and clear of any liens, encumbrances, lawful claims, demands of any person, and is not involved in any existing

or pending litigation. I agree to indemnify the Utah State Tax Commission, and all persons acting under direction of the Tax Commission, from any and all

liability and shall defend all litigation that may arise as a result of the issuance of said certificate.

Signature of applicant

Date subscribed and sworn

Place notary stamp in this space

NCIC Check Performed

Yes

Notary Public/M.V. Examiner signature

EO# _________________

Date _________________