OWNERSHIP BY REPOSSESSION
This form is for Nebraska lienholders only. Out-of-state
lienholders must use a form approved by their state of residence.
I being duly sworn deposes and say that
Representative of Secured Party
is/are the lawful owner(s) of the following
described motor vehicle/motorboat due to repossession.
Year Make Model
Vehicle Identification Number/Hull Identification Number
I further depose that:
1. the debtor has defaulted in connection with an obligation secured by the vehicle/boat
2. we have exercised our post-default remedies with respect to this collateral;
3. by reason of this exercise, we are acquiring the rights of the debtor in this collateral.
Name of Debtor
Address City State Zip
Nebraska Title Number Issued in County
Lien number Date Filed
Date of Original Contract Date of Transfer of Ownership
Affiant swears that he/she is making this statement for the purpose of having the designated County
Official issue a Certificate of Title in his/her name as indicated by the attached Application for Certificate
Affiant swears that he/she will warrant and defend the title and rights of this motor vehicle and protect the
issuing designated County Official from any damages that might arise from irregularities on same.
Signature of Representative of Secured Party Printed Name of Representative of Secured Party
Subscribed and Sworn to before me this day of ,
The lien shall not be released on the face of the title accompanying this Affidavit.
The date of Transfer of Ownership recorded above must be equal to or less than the notary date.
The date of Transfer of Ownership will be used as the purchase date on the Certificate of Title
issued pursuant to this Affidavit.
Printed on recycled paper Revised 8/09