VR450 VR 450

User Manual: VR450

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VR-450 (08-17)
Affidavit of Ownership – Moped, Motor Scooter & Off Road Vehicle
Purpose:	Use this form to certify ownership and apply for title and required decal of an off road motorcycle, ATV, snowmobile,
moped, motor scooter or UTV when the certificate of title or manufacturer’s certificate of origin is unavailable.
Instructions:	Complete this form in its entirety. All forms and applicable fees shall be submitted electronically to the Motor Vehicle
Administration via an ERT participant or online at www.mva.maryland.gov. For a listing of ERT participants, please
visit our website at www.mva.maryland.gov. The decal will be mailed to you and should be displayed on the rear of
the vehicle in a visible position.

OWNER INFORMATION
OWNER NAME (PRINT)

CO-OWNER NAME (PRINT)

OWNER’S SOUNDEX

DATE OF BIRTH

STREET ADDRESS

CO-OWNER’S SOUNDEX

CITY

DATE OF BIRTH

STATE

ZIP CODE

VEHICLE INFORMATION
TYPE OF VEHICLE: q Off Road Motorcycle
YEAR

MAKE

MODEL

q ATV q Snowmobile q Moped q Motor Scooter q UTV
BODY STYLE

DATE OF PURCHASE ________________________________

COLOR

VEHICLE IDENTIFICATION NUMBER (VIN)

PURCHASE PRICE ________________________________

LIEN INFORMATION
If this vehicle is subject to any liens or encumbrances, complete the following section(s). LIEN FILING FEE $20 for each lien filed. IF NOT SUBJECT TO A LIEN, WRITE
THE WORD “NONE” BELOW.
NAME OF SECURED PARTY

STREET ADDRESS OF SECURED PARTY

CITY

STATE

KIND OF LIEN (DESCRIBE)

DATE OF LIEN

AMOUNT OF LIEN

ZIP CODE

ACCOUNT NUMBER

CERTIFICATION
I/We certify under penalty of law that the operator(s) of the mopeds and motor scooters will carry evidence of required insurance and wear
protective headgear. Operators must also wear protective eye gear unless moped or motor scooter is equipped with a windscreen.
Knowingly making a false statement on this form is punishable by a fine of $1,000 and 10 years imprisonment.
I solemnly affirm under penalties of perjury and upon personal knowledge the contents of the foregoing document are true and correct to the best of
my knowledge and belief.
I/We further certify that should any legal action arise as a result of issuing a Certificate of Title my/our application for same, herein described, I/we
hereby bind ourselves, our heirs, assigns and personal representatives to indemnify and save harmless the Maryland Motor Vehicle Administration for
any loss or damage which may be asserted against or which may be sustained as a result thereof.
Any willful misinformation provided with fraudulent intent may be prosecuted under Maryland law.
OWNER’S SIGNATURE

OWNER’S PRINTED NAME

DATE

CO-OWNER’S SIGNATURE

CO-OWNER’S PRINTED NAME

DATE

Decal Number (MVA Use Only) _____________________
6601 Ritchie Highway, N.E., Glen Burnie, Maryland 21062
For more information visit our website at www.mva.maryland.gov, call 410-768-7000 or TTY for the hearing impaired: 1-800-492-4575.
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