Simple Power of Attorney Example - Indiana

Claim #: ________________
POWER OF ATTORNEY - STATE OF INDIANA
PLEASE PRINT
I/We, ___________________________________________________________________ ,
residing at ________________________________________________________________
in the county of ____________________________________________ do hereby appoint
____________________________________________________________________ as my
ATTORNEY IN FACT TO SIGN MY NAME AND COMPLETE INFORMATION IN
RELATION TO THE CERTIFICATE OF TITLE in Registration or Releasing my interest
in the vehicle/watercraft subject to the Registration as described below:
MAKE: ____________________________________________ YEAR _______________
I.D. NUMBER: ____________________________________________________________
TITLE NUMBER: _________________________________________________________
MILEAGE: _______________________________________________________________
I certify to the best of my knowledge that the odometer reading is the actual mileage of the
vehicle unless one of the statements below is checked.
( ) Mileage in excess of mechanical limits.
( ) Reading is not the actual mileage. WARNING - ODOMETER DISCREPANCY
Signed: ______________________________ _____________________________
Printed Name:______________________________ _____________________________
S.S. #: ______________________________ _____________________________
STATE OF INDIANA
COUNTY OF
SS: }
Sworn to before me, a Notary Public, in and for said County, this
_________ day of ________________________, 20________.
_____________________________________
(Notary Public Signature) (SEAL)
_____________________________________
(Printed Name)
My Commission Expires______________________
SF1940 BMV FORM 210 R1/94
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