Affidavit Of Assembly And Ownership For Automobile / Truck / Travel Trailer

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Form 761A

Oklahoma Tax Commission - Motor Vehicle Division

Revised 12-2015

MVC

Affidavit of Assembly and Ownership for Automobile / Truck / Travel Trailer

State of Oklahoma, County of ________________________________________

I hereby attest to the following facts and information. I understand that any false statement submitted in this affidavit subjects me to prosecution pursuant to 47 OS Section 4-108.

Please refer to the reverse for instructions and information on proper usage of this Affidavit.

Original receipts/bills of sale are required for each of the following components (see reverse). Each column must be completed.

Ownership Documentation

Description of Major Components

Purchased From

Serial Number

(i.e. Assigned Title, Bill of Sale)

Body and/or Cab:

List Serial Number/VIN of Body/Cab

In None, ChecK Box

Frame:

Front End Clip:

Rear End Clip:

Engine:

Transmission:

Total purchase price of all components utilized to assemble this vehicle: $

(Total Purchase Price is to reflect the total cost you paid for all parts utilized to construct this vehicle, less the cost of those parts on which sales tax was paid.)

I, the undersigned, state that to the best of my knowledge, there are no liens or claims on this assembled vehicle, or any of its component parts. I further agree to indemnify and save harmless the State of Oklahoma, its agencies, and

subsequent purchasers of said property, for any loss they may suffer resulting from titling and registering the above assembled vehicle and to agree to warrant and defend title to this vehicle against any and all claims.

__________________________________________________________________________________________________________

Print Firm Name or Individual Name (The title will be issued in this name)

_____________________________________________

Phone Number or Email Address: _____________________________

Owner Signature

Address: __________________________________________________________________________________________________

__________________________________________________________________________________________________________

City

State

Zip

Subscribed and sworn to before me this ________ day of __________________________, ___________.

Notary Seal