Fill and Sign the Tc 569c Survivorship Affidavit Rev 113 Utah State Tax Form

Signature of affidavit (survivor)DateNotary signature Date Subscribed and sworn to before me on this _____ day of _________________ 20____ by __________________________________________ Survivor’s name Survivor’s address (includes street, city, state, and ZIP) TC-569C Rev. 1/13 Survivorship Affidavit Division of Motor Vehicles · PO Box 30412, Salt Lake City, UT 84130 801-297-7780 or 1-800-368-8824 · Telephone Sectio n1-Vehicle Information Section 2 - Deceased Owner Information Section 3 - Survivor Information and Signature Deceased owner’s name City and state where death occurred Get forms online - tax.utah.gov Utah State Tax Commission X XDate of death Section 4 - New Owner Information Primary owner’s name (last, first, middle initial, or business name) Street address (primary owner) CityState ZIP code Mailing address, if different from Street Address (primary owner) City State ZIP code Co-owner’s name (if at different street address, check here and list on back) Pursuant to Utah Code 75-3-1201, I hereby transfer the Certificate of Title issued for the vehicle identified on this statement to the new owner shown below. I certify that the decedent left not more than four boats, motor vehicles, trailers, or semi-trailers, and that 30 days have elapsed since the death of the decedent. No appointment of a personal representative has been granted or is pending. The value of the entire estate subject to administration wherever located, excluding the boats, motor vehicles, trailers, or semi-trailers, less liens and encumbrances, does not exceed $100,000. I further certify that I am entitled to the vehicle and that this transfer will not prejudice the creditors of the decedent. Place notary stamp in space below Vehicle/Hull Identification Number (VIN/HIN) Year Make Model Body type License plate number State last registered Trailer lengthWatercraft length ft________ in________ ft________ in________