PRINT
CLEAR
T-16 (Rev 03-2013)
Affidavit of Repossession
State of Georgia
Page 1 of 2
County of _________________
This is to certify that the undersigned has repossessed the motor vehicle described below
because of the vehicle owner(s)’ failure to meet his or her obligation for settlement of a lien or
security interest on said vehicle
.
Important: Please read all of the instructions on page 2 of this form before completing.
Vehicle Owner(s)’ Full Legal Name(s)
Vehicle Owner(s)’ Address including C ity, S tate & Z ip C ode
Vehicle Year Model & Make
Vehicle Identification Number (VIN)
Current Title #
Lien or Security Interest Holder’s Name
Date of Repossession
Address
City, State & Zip Code
I, the undersigned, hereby certify that the information shown on this form is complete and
correct. I also certify that all holders of unsatisfied liens and/or security interests recorded
against this vehicle on the records of the Georgia Department of Revenue, Motor Vehicle
Division, have been duly notified to protect any interests they have in the vehicle.
Typed or Printed Name of Lien or Security Interest Holder
Authorized Signature
Date
Position or Job Title
Sworn to and subscribed before me this
________ of _________________,
Notary’s Telephone # including area code
________
(Day)
(Month)
(Year)
Date My Notary Commission Expires
Notary Public’s Signature & Notary Seal or Stamp
Notary’s
Printed Name
Note: If the title is not available, the repossessor must obtain a replacement title in the state
where the vehicle is currently titled before transferring ownership of the vehicle.