Affidavit of Loss or Release of Interest Template

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TD-420-040 (R/7/09)W Page 1 of 2 If you need special accommodation, please call (360) 902-3600 or TTY (360) 664-8885.
Affidavit of Loss/ Release of Interest
License /Registration number Year Make Series and body
Vehicle Identification Number (VIN) OR Vessel Hull Identification Number (HIN) Title number
Affidavit of Loss
The following is not in my possession because it was lost, stolen, destroyed, or mutilated: (Check the applicable box)
Title Registration Tab Decal Plate(s)
I certify under penalty of perjury under the laws of the State of Washington that the foregoing is true and correct. If signing
for a business, I have full authority to do so.
_______________________________ ______________________________ _______________
Signature Printed name (Position and company name if signing for business) WA driver license, ID, or UBI
_______________________________ ______________________________ _______________
Signature Printed name (Position and company name if signing for business) WA driver license, ID, or UBI
Notarization/ Certification for Affidavit of Loss
State of _____________________________________, County of __________________________________
Signed or attested before me on __________________ by ________________________________________
(Seal or stamp) ___________________________________________
Signature
___________________________________________
Printed or stamped name
Title ___________________________________ and ___________________________________________
Dealer or county/office number or notary expiration date
Release of interest
I certify under penalty of perjury under the laws of the State of Washington that the foregoing is true and correct. If signing
for a business, I have full authority to do so.
_______________________________ ______________________________ _______________
Signature of person releasing interest Printed name (Position and company name if signing for business) WA driver license, ID, or UBI
_______________________________ ______________________________ _______________
Signature of person releasing interest Printed name (Position and company name if signing for business) WA driver license, ID, or UBI
Gross weight license
I authorize this Gross Weight License to be transferred to the new owner and remain with the vehicle described above.
_______________________________ ______________________________ _______________
Signature of person authorizing transfer Printed name (Position and company name if signing for business) WA driver license, ID, or UBI
Notarization/ Certification for Release of Interest and/or Gross Weight transfer
State of _____________________________________, County of __________________________________
Signed or attested before me on __________________ by ________________________________________
(Seal or stamp) ___________________________________________
Signature
___________________________________________
Printed or stamped name
Title ___________________________________ and ___________________________________________
Dealer or county/office number or notary expiration date
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Affidavit of Loss or Release of Interest Template PDF

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