Form Mv-16 - Affidavit To Certify Immediate Family Relationship

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MV-16 (3-2013)
Affidavit to Certify Immediate Family Relationship
VIN: _______________________
Year: _____
Make: _______________________
This affidavit provides evidence that the above listed vehicle was transferred (whether gifted, purchased or
inherited) between persons who are immediate family members. (Spouse, Parent, Child, Sibling,
Grandparent, Grandchild).
By signing below we (Transferor and Transferee) acknowledge our relationships as immediate family members.
___________________________________________
__________________________________________
Transferor's Printed Name/Relationship
Transferee's Printed Name/Relationship
__________________________________________
___________________________________________
Transferor's Signature (if applicable)
Transferee's Signature
Sworn to and subscribed before me: This _________ day of ________________________, _________________
___________________________________________
___________________________________________
Notary’s Full Legal Printed or Typed Name
Notary’s Address
__________________________________________
Notary’s Signature
Notary’s Seal or Stamp
_____________________________
_____________________________
_______________________
_______________________
________________________
_______________________
Date my notary commission expires
Notary Public Phone Number
Email address
Any person who falsifies any information in this affidavit shall be subject to a penalty not to exceed
$2,500.00 as a state penalty and not to exceed $2,500.00 as a local penalty as determined by the state
revenue commissioner.

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