T-214 (Rev. 08-2005)
Web & MVD Manual
Purchaser’s Statement of Fact
This is to certify that I/we,
(Purchaser(s)’ Full Legal Name(s) – First, Middle & Last)
(Purchaser(s)’ Street Address Including City, State & Zip)
purchased or acquired ownership of the following described vehicle:
(Year Model & Make of Vehicle)
(Vehicle Identification Number - VIN)
(Seller(s)’/Transferor(s)’ Full Legal Name(s) – First, Middle & Last)
(Seller(s)’/Transferor(s)’ Street Address Including City, State & Zip)
This is to certify that the sale or ownership conveyance of this vehicle is made in good
faith and is not for the purpose of circumventing the provisions of §40-2-136 of the
seller(s)/transferor(s) of this vehicle will be deprived of custody and control of this motor
vehicle as the result of this sale.
I/we am aware of the facts contained in this Statement of Fact and further agree to
idemnify the Department of Revenue for any and all losses, which may occur from facts
contrary to those contained in this statement after a title is issued.
Sworn to and subscribed before me
(Purchaser(s)’/Transferee(s)’ Printed/Typed Name(s)
(Notary Public’s Signature & Notary Seal or Stamp)
(Purchaser(s)’/Transferee(s)’ Telephone # Including Area Code)
(Date Notary Commission Expires)
Note: This properly completed and signed form must accompany the new vehicle
owner’s title and license plate application.
Print this form!