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South Carolina Affidavit For Repossessed Motor Vehicle

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This affidavit provided by South Carolina Department of Motor Vehicles is one of the required forms completed by the applicant to register a repossessed vehicle.

South Carolina Affidavit For Repossessed Motor Vehicle
South Carolina Affidavit For Repossessed Motor Vehicle
South Carolina Department of Motor Vehicles
AFFIDAVIT FOR REPOSSESSED MOTOR VEHICLE
4034
(Rev.3/04)
(Entire Form to be Typed or Printed)
Under penalties of perjury, I ______________________________________ certify that all facts set forth
herein are true and correct and further certify that the holders of other unsatisfied liens recorded against this vehicle
on the records, Department of Motor Vehicles, Blythewood, S.C., have been duly notified to protect their interest in
the vehicle, if any, and this is to certify that the undersigned has repossessed the motor vehicle described below
because of the failure of the former owner to meet this obligation for settlement of a lien or mortgage on said
vehicle.
_____________________________________________________________________________________________
Name of Owner from Whom Vehicle Repossessed
_____________________________________________________________________________________________
Street City State Zip Code
_____________________________________________________________________________________________
Make Vehicle Identification Number (Serial) Title Number
_____________________________________________________________________________________________
Year Model Current License Number License Year Body Style
Method of Repossession _____ Terms of Lien or Mortgage
_____ Voluntary _____ Public Sale
Amount of Original Lien: $ _______________________ Date of Lien: _____________________________
Lienholder’s Name: ____________________________________________________________________________
Street, City, State, Zip Code: _____________________________________________________________________
Date of Repossession: __________________________________________________________________________
Signature of Lienholder: ___________________________________________ Title:________________________
Furthermore, this is to certify that for the value received $ ______________ the above vehicle has been assigned to:
_____________________________________________________________________________________________
NAME STREET CITY STATE ZIP CODE
for disposition or sale.
By: __________________________________________
Date: ________________________________________
Sales Tax Number: _____________________________
NOTICE: This form must accompany the Certificate of Title, which must be properly assigned to the
new owner on the back of the title.
(See instructions on reverse side)
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South Carolina Affidavit For Repossessed Motor Vehicle
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