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