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the Department has reasonable grounds to believe that the application contains a false or fraudulent statement;

I have failed to furnish required information or documents or any additional information the Department reasonably requires;

I have not paid at least one month’s registration tax or registered the vehicle under MS. 168.187.

7. I was told that I could obtain a title for the vehicle only if I posted a bond in the amount of $______________ .

  • I have posted the bond.

  • I have not posted the bond.

Dated:

Signature (Sign only in front of notary public or court administrator.)

Sworn/affirmed before me this

day of

,

.

Name: Address: City/State/Zip: Telephone:

Notary Public \ Deputy Court Administrator

See Next Page for Affidavit of Mailing

MOV102

State

ENG

Rev 5/04

www.courts.state.mn.us/forms

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