Form Vtr-122 - Rights Of Survivorship Ownership Agreement For A Motor Vehicle
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1
2Rights of Survivorship Ownership
Agreement for a Motor Vehicle
Vehicle Information
Vehicle Identification Number
Year
Make
Body Style
Model
Part A: Individuals Married to One Another
First Name
Middle Name
Last Name
Suffix (if any)
1
First Name
Middle Name
Last Name
Suffix (if any)
2
Part B: Individuals Not Married to One Another
First Name
Middle Name
Last Name
Suffix (if any)
3
First Name
Middle Name
Last Name
Suffix (if any)
4
First Name
Middle Name
Last Name
Suffix (if any)
5
First Name
Middle Name
Last Name
Suffix (if any)
6
Part C: Spouse Not Included in Rights of Survivorship
First Name
Middle Name
Last Name
Suffix (if any)
7
Certification
– State law makes falsifying information a third degree felony
We, the individuals whose signatures appear below affirm our understanding the motor vehicle described above from this day
forward will be held jointly, and in the event of the death of any person named in this agreement, the ownership of the vehicle will
transfer to the survivor(s). Select one:
We, the individuals named in Part A and whose signatures appear below, agree to joint ownership of the motor vehicle
☐
described above. (Note: Only Part A should be completed if this certification is checked.)
We, the individuals named in Part A and whose signatures appear below, agree to joint ownership of the motor vehicle
☐
described above AND also agree to joint ownership of the motor vehicle with the individual(s) listed in Part B whose signatures
appear below. (Note: Both Parts A and B should be completed if this certification is checked.)
We, the individuals named in Part B and whose signatures appear below, affirm we are not married to each other, and agree to
☐
joint ownership of the motor vehicle described above. (Note: Only Part B should be completed if this certification is checked.)
Signature of Spouse (listed in row 1, if applicable)
Date
Signature of Spouse (listed in row 2, if applicable)
Date
Signature of Individual (listed in row 3, if applicable)
Date
Signature of Individual (listed in row 4, if applicable)
Date
Signature of Individual (listed in row 5, if applicable)
Date
Signature of Individual (listed in row 6, if applicable)
Date
Certification for Spouse Not Included in Rights of Survivorship
– Required if Part C is completed
I, the individual listed in Part C and whose signature appears below, affirm I am not involved in the rights of survivorship agreement
but my spouse (listed in row #
) is party to the rights of survivorship agreement. I attest the motor vehicle described above,
subject to the rights of survivorship agreement, is my spouse’s separate property, and I have no interest in the motor vehicle.
Signature of Spouse (listed in row 7)
Date
VTR-122 Rev 08/16
Form available online at
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