Affidavit of Loss - Washington

X
X
Notarization/ Certification
State of , County of
Signed or attested before me on by
(Seal or stamp)
Notary signature
Notary printed or stamped name
Title and
Dealer or county/office number or notary expiration date
Affidavit of Loss/ Release of Interest/
Gross Weight License
When completed, mail or take this original, notarized form to any vehicle and vessel licensing office.
License/Registration number Year Make Series/ Body
Vehicle Identification Number (VIN) or Vessel Hull Identification Number (HIN)
What are you reporting?
Check all that apply
Affidavit of loss ....... Yes No
The following item is not in my possession because it was lost, stolen, destroyed, or mutilated.
Title
Registration
Ta b
Decal
Plates
Release of interest .... Yes No
I release interest in the vehicle or vessel described above.
Gross weight license .. Yes No
I authorize the transfer of this gross weight license to the new owner to remain with the vehicle described above.
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.
PRINT or TYPE Name of first owner
(Area code) Telephone number
Washington driver license, ID, or UBI
Position and company name if signing for a business
Signature
PRINT or TYPE Name of second owner
(Area code) Telephone number
Washington driver license, ID, or UBI
Position and company name if signing for a business
Signature
We are committed to providing equal access to our services.
TD-420-040 (R/11/14)WA If you need accommodation, please call (360) 902-3770 or TTY (360) 664-0116.
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