Free 53330.FH11 - Indiana

REQUEST FOR TRANSFER STATEMENT
State Form 53330 (8-07) BUREAU OF MOTOR VEHICLES

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NOTE: This form must be accompanied by an application for an Indiana certificate of title with associated fees, a certified copy of the inventory / floor plan financing contract, a perfected copy of the financing statement filed with the Indiana Secretary of State, and the Vehicle Identification Number (VIN) inspection.
Year of vehicle Model of vehicle Series / body type of vehicle

Vehicle identification number (VIN)

I depose and say upon my oath that I am the _____________________________________________________________________ of
Title or position

___________________________________________________________________________________________________, located at
Name of secured party

____________________________________________________________________________________________________________,
Mailing address (number and street, city, state, and ZIP code) of secured party

that we have exercised our post-default remedies by reason of a security agreement with respect to the above specified vehicle / collateral which was inventory held for sale or lease by the debtor or leased by the debtor as lessor as described by IC 26-1-9.1-311(d), that the debtor is in the business of selling or leasing goods of that kind, and that, by reason of the exercise, a transferee who is ___________________________________________________________________________________________________, located at
Name of transferee

____________________________________________________________________________________________________________,
Mailing address (number and street, city, state, and ZIP code) of transferee

has acquired the rights of the debtor in the collateral. I further certify that we have lawfully repossessed this vehicle on ______________________________, from ________________________________________________________________, located at
Date of repossession (month, day, year) Name of debtor

____________________________________________________________________________________________________________,
Mailing address (number and street, city, state, and ZIP code) of debtor

that the debtor has defaulted in connection with an obligation secured by this specified collateral, and that an application for an Indiana certificate of title, which accompanies this Request for Transfer Statement is made in accordance with IC 26-1-9.1-619 and IC 9-17-3-5 and is based upon the repossession of this vehicle.

I swear or affirm that the information I have entered on this form is correct. I understand that making a false statement on this form may constitute the crime of perjury.
Signature of affiant Date of signature (month, day, year)

Printed name of affiant