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MOTOR VEHICLE OWNERSHIP AFFIDAVIT H-115 Rev. 10-2014
STATE OF CONNECTICUT
DEPARTMENT OF MOTOR VEHICLES TITLE UNIT FULL NAME(S) (First, Middle Initial, Last)
STATEMENT OF IDENTITY
VEHICLE DESCRIPTION
RESIDENT ADDRESS
(Number and Street)
YEAR
MAKE
(City or Town)
(State)
(Zip Code)
MODEL
VEHICLE IDENTIFICATION NUMBER (VIN)
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
OATH AND ACKNOWLEDGMENT
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 above. 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 understand that if I make a statement which I do not believe to be true, with the intent to mislead the Commissioner, I will be subject to prosecution under the above-cited laws. PRINTED NAME(S) OF OWNER(S)
