Free Utah Ownership Statement, TC-569A MVA - Utah

Division of Motor Vehicles UTAH STATE TAX COMMISSION
210 North 1950 West Salt Lake City, Utah 84134 Telephone (801) 297-7780 or 1-800-DMV-UTAH

TC-569A MVA Rev. 9/01

Clear form

Ownership Statement
Owner Information
Primary Owner's Name (Last, First, Middle Initial)

Address Information
Street Address

Secondary Owner's Name (Last, First, Middle Initial)

City

State

ZIP Code

Business Name

FEIN

P.O. Box

Fleet Number

Unit Number

City

State

ZIP Code

VIN/HIN

Year

Make

Model

State last registered

License number

Utah Certificate of Title number

Odometer Disclosure - Required
Enter mileage, no tenths Reflects the actual mileage for this vehicle Reflects the amount of mileage in excess of the odometer mechanical limits Is not the actual mileage for this vehicle Warning - Odometer discrepancy Name of applicant Date of vehicle possession

Address (include city, state, and ZIP Code)

Value of Vehicle
(If the fair market value of the vehicle exceeds $1,000, a surety bond may be required, not to exceed twice the fair market value of the vehicle.)

$ Facts and Indemnification Agreement
Name or company from whom the vehicle was acquired

Address (include city, state, and ZIP Code)

Explain why outstanding certificate of title was not obtained or why the attached title is not negotiable. Explain in detail how and why you acquired the vehicle, who was involved, when did you acquire the vehicle, working condition of the vehicle, etc.

Warning, Fraudulant application and falsification of documents is a felony under Utah Law. Under penalties of perjury, I declare that to the best of my knowledge and belief, this statement is true, correct, and complete. I further state that to the best of my knowledge, the vehicle is free and clear of any liens, encumbrances, lawful claims, demands of any person, and is not involved in any existing or pending litigation. I agree to indemnify the Utah State Tax Commission and all persons acting under direction of the Commission, from any and all liability and shall defend all litigation that may arise as a result of the issuance of a certificate of title in my name. Signature of applicant Date

NCIC Check Performed Yes No TX ID Date