Fill and Sign the Financial Affidavit Long Form Thirteenth Judicial Court

Power of Attorney, Bill of Sale and Odometer Statement "ANY PERSON WHO KNOWINGLY FILES A STATEMENT OF CLAIM CONTAINING ANY FALSE OR MISLEADING INFORMATION IS SUBJECT TO CRIMINAL AND CIVIL PENALTIES."ö ö Claim Number: Date of Incident or Theft: POWER OF ATTORNEY AND BILL OF SALE YEAR, MAKE, AND MODEL: VIN: LICENSE NUMBER AND STATE: KNOW ALL PERSONS BY THESE PRESENT, THAT I/WE, THE UNDERSIGNED, for value received, on this day of , in the year , grant, bargain, sell, and assign all rights, title, and interest in and to the motor vehicle described above and do hereby make, constitute, and appoint of PRUDENTIAL PROPERTY AND CASUALTY INSURANCE COMPANY my/our true and lawful attorney in fact for me/us and my/our name(s) to execute and to sign my/our name(s) to assignment of titles, transfer of titles, application for titles, or any other forms involving title to the above motor vehicle. This Power of Attorney shall remain in effect until such time as the title to this motor vehicle is out of my/our name(s), hereby satisfying and confirming all that the said attorney or substitutes shall do therein by virtue of these present. ODOMETER MILEAGE STATEMENT I, , state that the odometer upon transfer of the vehicle described above, now reads (no tenths) miles/kilometers and to the best of my/our knowledge that it reflects the actual mileage of the vehicle, unless one of the following statements is checked. Check one only (if applicable): I/we hereby certify to the best of my knowledge that the odometer reading reflects the amount of mileage in excess of its mechanical limits. I/we hereby certify that the odometer reading is not the actual mileage. WARNING - ODOMETER DISCREPANCY SELLER/OWNER CO-OWNER(S) (If any) 2ND CO-OWNER(S) ADDRESS/CITY/STATE PCD 3284/NJ Ed. 8/99 SIGNATURE PRINTED NAME DATE SIGNATURE PRINTED NAME DATE SIGNATURE PRINTED NAME DATE