Form Os/ss-52 - Application For Duplicate Certificate Of Ownership Page 4
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4New Jersey
NJ MVC/ Special Title Unit
225 E State Street
Motor Vehicle Commission
Trenton, NJ 08666-0017
BUYER’S DECLARATION - EMERGENCY APPLICATION FOR VEHICLE TITLE
Buyer’s Information:
____________
Date:
___________________________________
________________________________
First Name
Last Name
__________________________________________________________________________________________
Address
City
State
Zip Code
I purchased a vehicle on _______________ from __________________ but never received the (check all
Date of Sale
Seller’s Name
that apply):
-Title
-Plates
-Registration
Vehicle information:
__________
__________________
___________________________________________________
Year
Make
Vehicle Identification Number (VIN)
__________________________________________________________________________________________
Seller’s Full First and Last Name and/or Name of Business
____________________________________________________________________________________________________________
Address
City
State
Zip Code
Statement How Vehicle Came Into Your Possession: ______________________________________________
_________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
I ACKNOWLEDGE, that in making this Declaration, I am inducing the New Jersey Motor Vehicle Commission (“NJMVC”)
to issue a vehicle title for the above-described vehicle purchased from the seller listed above and that although the NJMVC
may issue the same as a convenience under the circumstances, by doing so, the NJMVC makes no assurances against future
claims against this vehicle, and I therefore agree to defend, indemnify and hold harmless the State of New Jersey, the NJMVC,
their officers, employees and agents from and against any and all liability, loss, expense, attorneys’ fees, or injury or damages
arising out of any such claim.
I FURTHER ACKNOWLEDGE that this Declaration is being made for the purpose of applying for an un-issued vehicle title,
registration and/or plates as described above, and that any knowing or willful misrepresentation or false statement submitted
in connection with this Declaration may subject me to criminal punishment, including fines and/or imprisonment.
_________________________________
___________________________________
Signature
Print Name
__________________________________________________________________________________________
Driver License Number or Corporation Code
___________________________________________
:
Notary Public
Seal
OS/SS-150 (R12/07)
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