Form 735-7116a - Affidavit To Establish Financial Interest In A Vehicle

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AFFIDAVIT TO ESTABLISH FINANCIAL
DMV
INTEREST IN A VEHICLE
DEPARTMENT OF TRANSPORTATION
(Instructions on back)
DRIVER AND MOTOR VEHICLE SERVICES
1905 LANA AVE NE, SALEM OREGON 97314
Use this form when you have a financial interest in a vehicle and need to obtain
the personal information from DMV’s vehicle record in order to obtain a release
of interest or a signature required for a title transaction.
I, ________________________________________________________ ,
Print Name Here
of__________________________________________________________________ ,
Print Address Here
state that I have a financial interest in the vehicle described below.
PLATE NUMBER
YEAR
MAKE
VEHICLE IDENTIFICATION NUMBER (VIN)
TITLE NUMBER
I am submitting copies of the following document(s) for consideration in determining my claim to
have a financial interest in the vehicle: (check all that apply)
Bill of sale
Divorce decree
Contract/purchase agreement
Inheritance affidavit
Odometer disclosure
Court order
Oregon title/salvage title
Other – Anything not listed that you feel is
Security agreement
evidence that you have an interest in the
Small Estate Certification
vehicle. Include a letter of explanation.
Lease agreement
OR:
I am an owner listed on DMV’s vehicle record.
The information I am providing is true and correct. I am requesting the personal information
from DMV’s vehicle record because I have a financial interest in the vehicle and need to obtain
a release of interest or a signature required for a title transaction.
I understand that this form and the document(s) submitted as evidence of my interest will not
be used to establish any type of ownership in the vehicle.
I understand that it is a Class A misdemeanor to knowingly obtain or use personal information
in connection with a motor vehicle record in violation of ORS 802.175 to ORS 802.187. This
Class A misdemeanor is punishable by a jail sentence of up to one year, a fine of $5,000, or
both.
SIGNATURE
X
State of _______________________ County of _______________________
N
O
Subscribed and sworn before me this _________ day of __________, 20 ___
T
.
A
by ___________________________________________________________.
R
Y
X
SIGNATURE OF NOTARY PUBLIC
735-7116A (4-04)
STK# 300068

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