ONE AND THE SAME
CERTIFICATE

 Vehicle Identification Number

Year

  Make

 

 Name On Document
 Individual Name (first, middle, last, suffix) or Organization Name

I certify that the two names above are one and the same person, or one and the same organization.

 Representative Name (if Organization Name above)
 Signature
 

 

   Subscribed and sworn to before me this date.

  Notary or MVD Agent Signature and Seal
 
Date
 		  County
 		 State
 		  Commission Expires