Affidavit To A Fact - Kansas Department Of Revenue
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1
2KANSAS
DEPARTMENT OF REVENUE
DIVISION OF VEHICLES
TOPEKA, KANSAS 66626-0001
Complete vehicle information and check appropriate statement(s).
N
R
.
Please Type or Print Clearly
OTARIZATION IS
EQUIRED
Must be Completed
Year
Make
ID #
I, the undersigned, certify that the above referenced vehicle was presented
as a gift to
Donor Signature
I, the undersigned, certify that
and
are one and the same person.
I, the undersigned, certify that I am disclaiming ownership of the above referenced vehicle.
(Name addition) We, the undersigned, certify the above referenced vehicle
assignment was not properly completed at time of purchase.
Name of person to be added on assignment:
(Both parties must sign below.)
I, the undersigned, certify that the above referenced vehicle was not at any time operated
. (Report full calendar years only.)
during the year(s) of
and
(Renewals, only)
I, the undersigned, certify that I am the
of
Relationship
.
(Applicant/Military Personnel)
I, the undersigned, certify that the above referenced vehicle has been modified to meet all safety requirements as per
Kansas statutes, for the purpose of obtaining Kansas title and registration.
I certify that all information and statement(s) made above are true to the best of my knowledge.
Affiant’s Signature(s)
Sworn and signed before me on this:
Month
Day
Year
State of
County of
NOTARY SEAL HERE
Notary Public
My Commission Expires:
TR-12 (Rev. 01/00)
Must be fully completed
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