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Affidavit of Facts to Accompany Indemnity Bond

The following affidavit has to be accompanied by thorough details when submitted by an applicant who is applying for a title supported by an indemnity bond.

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MVR-92H 
(Rev. 09/12) 
 	
AFFIDAVIT OF FACTS TO ACCOMPANY INDEMNITY BOND 	
 
The following questions must be answered in detail and this form must be attached to any application for title 
that is supported by an Indemnity Bond. Furnish any document in your possession showing proof of ownership. 
(Examples would be a Title, Bill of Sale, Conditional Sales Contract, Invoices, Out of State Registrations). 
 
 	
    Year      Make           Body Style                                  Vehicle Identification Number 
1. How did you acquire the vehicle?  List the seller’s full name, full address, and phone number. 
 
 
2. List the date you acquired the vehicle. 
 
3. Is the vehicle currently titled in North Carolina?  If no, list the last title state. 
 
 
4. Does the VIN plate appear on the vehicle?  If so, please give the location. 
 
 
5. Are there any liens outstanding on the vehicle?  If so, list the lienholder’s name and provide a lien release. 
 
 
6. Has the vehicle been wrecked?  If so, list the major parts replaced. 
 
 
7. If you were given a title at the time of purchase, why can it not be furnished at the present time? 
 
 
8. Explain, in detail, why the seller did not give you a properly assigned title for the vehicle. 
 
 
 
 
 
9. What steps have you taken to contact the seller/previous owner to obtain proper ownership documentation? 
 
 
I (we) certify that the above information is correct to the best of my knowledge. 
OWNER’S SIGNATURE  _________________________________________________________________________ 
 
 
Date ______________  County _________________________________________ State ______________________ 
I certify that the following person(s) personally appeared before me this day, each acknowledging to me that he or 
she voluntarily signed the foregoing document for the purpose stated therein and in the capacity indicated. 
____________________________________________________________________ [NAME(S) OF PRINCIPALS(S)]  
Notary            Notary Printed 
Signature _______________________________________  or Typed Name _________________________________ 
             
      (SEAL)            My Commission Expires __________________________
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Next: Affidavit of Facts Surrounding The Incorrect Assignment of A Manufacturers Certificate of Origin or A Certificate of Title Previous: Affidavit to Release Instant Title
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