Motor Vehicle Ownership Affidavit
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1MOTOR VEHICLE OWNERSHIP AFFIDAVIT
H-115 Rev. 5-2012
STATE OF CONNECTICUT
DEPARTMENT OF MOTOR VEHICLES
TITLE UNIT
FULL NAME(S) (First, Middle Initial, Last)
STATEMENT
OF
(City or Town)
(State)
(Zip Code)
RESIDENT ADDRESS
(Number and Street)
IDENTITY
YEAR
MAKE
MODEL
VEHICLE
DESCRIPTION
VEHICLE IDENTIFICATION NUMBER (VIN)
I (we) are the lawful owners of the above described vehicle. I (we) do not have knowledge of any
liens or encumbrances on the said vehicle, except as indicated below. I (we) understand that the
statements made herein to the Commissioner are given under penalty of false statement, in
accordance with the provisions of sections 14-110 and 53a-157b of the Connecticut General
Statutes, as amended. I (we) further understand that the Commissioner may revoke any
certificate of title and/or registration issued in reliance on the statements made herein, if the
Commissioner becomes aware of any contrary or additional material facts, and that, in such
event, I may have liability to any third person (or persons) or party (or parties) who has (have) a
legal interest in the above described vehicle.
I (WE) CAME INTO POSSESSION AND OWNERSHIP OF THE ABOVE DESCRIBED VEHICLE AS FOLLOWS (Include name of prior owner, seller, or transferor)
OWNERSHIP
STATUS
TO THE BEST OF YOUR KNOWLEDGE, ARE THERE ANY LIENS OR ENCUMBRANCES ON THE ABOVE DESCRIBED VEHICLE?
NO
YES (If "YES", indicate names and addresses below)
LIEN
STATUS
PRINTED NAME(S) OF OWNER(S)
SIGNATURE(S) OF OWNER(S)
OATH
X
AND
ACKNOWLEDG-
PLACE SWORN
DATE SWORN
SIGNATURE (Notary Public, J/P, Commissioner of Superior Court, DMV Official)
SUBSCRIBED AND
MENT
SWORN BEFORE ME
X
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