Fillable Printable Simple Power of Attorney Example - Indiana

Simple Power of Attorney Example - Indiana

Claim #: ________________

POWER OF ATTORNEY - STATE OF INDIANA

PLEASE PRINT

I/We, ___________________________________________________________________ ,

residing at ________________________________________________________________

in the county of ____________________________________________ do hereby appoint

____________________________________________________________________ as my

ATTORNEY IN FACT TO SIGN MY NAME AND COMPLETE INFORMATION IN

RELATION TO THE CERTIFICATE OF TITLE in Registration or Releasing my interest

in the vehicle/watercraft subject to the Registration as described below:

MAKE: ____________________________________________ YEAR _______________

I.D. NUMBER: ____________________________________________________________

TITLE NUMBER: _________________________________________________________

MILEAGE: _______________________________________________________________

I certify to the best of my knowledge that the odometer reading is the actual mileage of the

vehicle unless one of the statements below is checked.

( ) Mileage in excess of mechanical limits.

( ) Reading is not the actual mileage. WARNING - ODOMETER DISCREPANCY

Signed: ______________________________ _____________________________

Printed Name:______________________________ _____________________________

S.S. #: ______________________________ _____________________________

STATE OF INDIANA

COUNTY OF

SS: }

Sworn to before me, a Notary Public, in and for said County, this

_________ day of ________________________, 20________.

_____________________________________

(Notary Public Signature) (SEAL)

_____________________________________

(Printed Name)

My Commission Expires______________________

SF1940 BMV FORM 210 R1/94