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STATEMENT OF FACT <br />MOPED /BICYCLE OWNERSHIP <br />1, CERTIFY THAT 1 AM THE OWNER OF THE FOLLOWING <br />DESCRIBED MOPED /BICYCLE: MAKE AND TYPE: SERIAL NO: <br />THAT SAID MOPED /BICYCLE WAS ACQUIRED FROM: <br />ON OR ABOUT: , 20 <br />THAT THE PREVIOUS OWNER(S) DID TRANSFER HIS /HER INTEREST /OWNERSHIP TO THE SAID MOPED /BICYCLE TO THE <br />UNDERSIGNED; THAT ALL EFFORTS TO LOCATE THE PREVIOUS OWNER(S) TO OBTAIN THE EVIDENCE OF PROOF OF <br />OWNERSHIP HAVE BEEN UNSUCCESSFUL, AND; <br />1 AGREE TO INDEMNIFY AND SAVE HARMLESS THE DIRECTOR OF FINANCE, COUNTY OF HAWAI-I AND SUBSEQUENT <br />PURCHASERS OF SAID MOPED /BICYCLE FOR ANY LOSS RESULTING FROM THE ISSUANCE OF A CERTIFICATE OF <br />REGISTRATION COVERING THE SAME AND ON ALL SUBSEQUENT RECORDING OF TRANSFERS OF REGISTRATION. <br />Signed this <br />day of <br />(PLACE NOTARY SEAL HERE) <br />Subscribed and sworn to before me this <br />day of <br />Notary Public, <br />State of <br />My Commission expires <br />20 <br />20 Signature <br />STATE OF HAWAII NOTARY CERTIFICATION <br />(PLACE NOTARY SEAL HERE) <br />Document Date: # of pages <br />Notary Name: Circuit <br />Document Description: <br />Notary <br />Signature <br />Hawaii County is an Equal Opportunity Provider and Employer <br />Date <br />Created 04/28/09 <br />Hawai'i County is an Equal Opportunity Provider and Employer Updated 2/5/2013 <br />