1. There are no liens or encumbrances on the described Vehicle.
  2. All parties:

☐ agree;

agree
do not agree

☐ unknown;

unknown

that the Petitioner is the owner of the Vehicle.

WHEREFORE, Petitioner requests the Court to enter an order directing the Pennsylvania Department of Transportation to issue a title in Petitioner's name, provided Petitioner complies with the costs, fees, taxes and other paperwork required by the Pennsylvania Department of Transportation to accomplish this purpose.

Petitioner:

Signature

Print Name

Date: _____

Date

(3/24)

2