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Iowa Power of Attorney Authorization Form

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Iowa Power of Attorney Authorization Form
Iowa Power of Attorney Authorization Form
Form 411021
To complete the following:
1. Application for Certificate of Title
2. Assignment of Certificate of Title
3. Application for Replacement Certificate of Title
4. Application for Notation of Security Interest
5. Motor Vehicle Odometer (Mileage) Statement
6. Damage Disclosure Statement
7. Application for Refund for a Leased Vehicle.
Power of Attorney must be surrendered with application
Color of Vehicle
(SEAL) Notary Public
First Name Middle Name Last Name
Disclosure Statement: The information requested will be used by the county treasurer and Department of Transportation to allow vehicle
owners to appoint an attorney in fact to sign documents pertaining to titling and registering vehicles.
All of the information is required and failure to provide required information would result in the denial of use of the power of attorney form.
Address in Full
That the undersigned
a Resident of County, State of
does hereby make, constitute and appoint
the undersigned's lawful attorney for undersigned and in undersigned's name to make and execute application for
Certificate of Title, Assignment of Title, and all of my title and interest in and to the following described motor vehicle, to
make application for replacement title, or application for notation of security interest covering the following described
motor vehicle to wit:
Iowa title number, when applicable
The undersigned authorizes said Attorney to include in such assessment, such statements and warranties as to
mortgages, security interests and encumbrances upon the said motor vehicle as he may believe to be true and the
undersigned hereby ratifies and confirms each and every act which said attorney may do pursuant to power herein granted.
Signed at
This day of , .
, Owner
On this day of , , before me, a Notary Public in and for said
County and State, personally appeared
the person who executed the foregoing Power of Attorney and acknowledged the same to be his voluntary act and deed.
Witness my hand and Notary Seal the day and year last above written.
Iowa Power of Attorney Authorization Form