Fillable Form Tr-84 - Repossession Affidavit printable pdf download

KANSAS

REPOSSESSION AFFIDAVIT

DEPARTMENT OF REVENUE

DIVISION OF VEHICLES

Please Type or Print Clearly

State of Kansas, County of

ss.

Secured

Party’s Name

, principal place of business is

Address

City

ZIP

’

ECURED

ARTY

ONTACT

ERSON

Name

Phone No.:

Email:

Date Security Agreement was

Date Vehicle was

Made, Executed & Delivered

Repossessed

Debtor(s) Name

, of

Address

City

ZIP

Vehicle was repossessed in accordance to Kansas statutes

Voluntary Surrender by Debtor

Peaceable Seizure

and under the terms of the security agreement through:

Replevin

Other

VEHICLE INFORMATION

Year

Make

Style

VIN

I, the undersigned, certify to the best of my knowledge that the odometer reading is:

‚

Tenth’s

∙

and this reading is (Must check one of the below):

Actual

The odometer reading stated is in excess of its mechanical limits

The odometer reading is not actual mileage*

*WARNING - ODOMETER DISCREPANCY

I, the undersigned have read and understand the warning below and hereby certify that: I am authorized to act on behalf of and file this affidavit for the secured party

shown above. That a security agreement was made, executed and delivered on the vehicle shown above. A certified notarized copy of the security agreement is

attached to this affidavit. Due to default, the secured party did on the date shown above repossess said vehicle in accordance with Kansas statutes and under terms

specified in the security agreement. Therefore, the secured party now claims said vehicle and title document by reason of such default and repossession.

Reasonable efforts were made to obtain the debtor’s certificate of title. By my signature I swear or affirm that the information contained in this affidavit is true and

correct, the supporting documentation listed on the back of this affidavit has been attached and all requirements and laws of the State of Kansas have been complied

with. I am aware the law provides severe penalties for making false statement under oath.

Signature of

Authorized Agent

Date

Hand Printed Name of

Agent’s Position

Person Signing Above

w/Secured Party

VIN INSPECTION EXEMPTION

When a vehicle is titled and registered outside the State of Kansas, but is financed originally by a financial institution chartered in the State of Kansas, and is

repossessed In another state and

SUCH VEHICLE WILL NOT BE RETURNED TO

ANSAS

BY THE FINANCIAL INSTITUTION OR A PURCHASER

BEFORE BEING TITLED IN ANOTHER

the VIN inspection will not be required for the purpose of obtaining a valid Kansas repossession title.

JURISDICTION

Financial institutions claiming VIN inspection exemption MUST provide the following information as certification of this claim.

Kansas Financial Institution’s Name

: Year

Make

Style

VIN

EHICLE

This vehicle is currently located in the State of

I, the undersigned authorized representative of the Kansas Financial Institution listed herein, have read and understand the warning below and hereby certify: the vehicle described in

this VIN Inspection Exemption has been repossessed and WILL NOT BE RETURNED TO KANSAS, BY THE FINANCIAL INSTITUTION OR A PURCHASER

BEFORE BEING TITLED

IN ANOTHER JURISDICTION. By my signature I swear or affirm that the information contained in this exemption affidavit is true and correct and that all requirements and laws of the

State of Kansas have been and will be complied with. I am aware the law provides severe penalties for making false statement under oath

Signature of

Title or Position

Authorized Agent

with Secured Party

WARNING:

Kansas statutes KSA 21-3711 provides that

FALSIFYING INFORMATION ON ANY REQUIRED DOCUMENT IS

. KSA 21-3710 deals with forgery;

A SEVERITY LEVEL

NONPERSON FELONY

FORGERY IS KNOWINGLY