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I, the undersigned afant, certify that I am the assigned owner of the following vehicle:
On ___________, I purchased the above vehicle from _____________________________________
I hereby conrm no contract or bill of sale was prepared at the time of purchase and I am unable to
obtain a contract or bill of sale from the seller.
Therefore, I hereby declare a total purchase price of $ ______________________was paid for the
above listed vehicle, excluding credit for any trade in.
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