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Utah State Tax Commission

TC-569C Rev. 5/11

Survivorship Affidavit

Division of Motor Vehicles · PO Box 30412, Salt Lake City, UT 84130 · Telephone 801-297-7780 or 1-800-368-8824

Section 1 - Vehicle Information Vehicle/Hull Identification Number (VIN/HIN) License plate number Year State last registered Make Trailer length ft________ in________ Section 2 - Deceased Owner Information Deceased name City and state where deceased died Date of death Model Watercraft length

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Body type

ft________ in________

Section 3 - Survivor Information and Signature Survivor's name Survivor's address (includes street, city, state, and ZIP) Subscribed and sworn to before me on this _____ day of _________________ 20____ by __________________________________________ Place notary stamp in space below

Pursuant to Utah Code, I hereby transfer the Certificate of Title issued for the vehicle identified on this statement to the new owner shown below. I certify that the decedent left not more than four boats, motor vehicles, trailers, or semi-trailers, and that 30 days have elapsed since the death of the decedent. No appointment of a personal representative has been granted or is pending. The value of the entire estate subject to administration wherever located, excluding the boats, motor vehicles, trailers, or semi-trailers, less liens and encumbrances, does not exceed $100,000. I further certify that I am entitled to the vehicle and that this transfer will not prejudice the creditors of the decedent.

Signature of affidavit (survivor) X Section 4 - New Owner Information

Date

Notary signature X

Date

Primary owner's name (last, first, middle initial, or business name) Street address (primary owner) Mailing address, if different from Street Address (primary owner)

Co-owner's name (if at different street address, check here City City State State

and list on back)

ZIP code ZIP code

Information

TC-569C, Survivorship Affidavit

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