Fill and Sign the Wc 4 Case Progress Report Georgia State Board of Workers Compensation Case Progress Report 0 Initial Board Claim No Form

BILL OF SALE OF AUTOMOBILE To be completed upon sale of motor vehicle. State of Washington County of _______________ $ _______________ FOR AND IN CONSIDERATION OF ___________________ Dollars ($___________) cash in hand, paid me this day in full by____________________________, (Buyer(s), ____________________________, “Seller(s)”do hereby bargain and sell to Buyer(s) the following personal property: One (1) Motor Vehicle Make _____________________ Model Body Type ________________ ________________ Vehicle Identification Number (VIN) ________________ Year: _____ The said property I guarantee is my own and free of all claims and offsets of any and all kinds. To have and to hold the same unto Buyer(s) and Buyer(s) executors, administrators and assigns, forever. Seller(s) hereby covenant to and with Buyer(s)that Seller(s) is the true and lawful owner(s) of the above-described motor vehicle, that the same is free from all encumbrances whatsoever except __________________________ (lienholder), that Seller(s) has good right to sell the same as aforesaid, and that Seller will warrant and defend the same against all lawful claims and demands whatsoever except the above lien, if any. Seller(s) ________________________ Signature Print Name: _______________________ ________________________ Signature Print Name: _______________________ SWORN TO AND SUBSCRIBED BEFORE ME, this the ____ day of ________________, 20____. My Commission Expires: ________________________ ____________________________ NOTARY PUBLIC ODOMETER DISCLOSURE STATEMENT To be competed by Transferor (Seller) Federal law (and State law, if applicable) requires that you state the mileage upon transfer of ownership. Failure to complete or providing a false statement may result in fines and/or imprisonment. I, _______________________________ , state that the odometer now reads _______________ miles and to the best of my knowledge that it reflects the actual mileage of the vehicle described below, unless one of the following statements is checked. I hereby certify that to the best of my knowledge the odometer reading reflects the amount of mileage in excess of its mechanical limits. I hereby certify that the odometer reading is NOT the actual mileage. WARNING - ODOMETER DISCREPANCY. Make _______________ Model Body Type _______________ _______________ Vehicle Identification Number (VIN) _______________ Year: _______________ Signature of Transferor (Seller): __________________________ Transferor's (Seller's) Information Transferor's Name (Please Type or Print): Street Address: City: State: Zip: Transferee's (Buyer's) Information Transferee's Name (Please Type or Print): Street Address: City: State: Zip: Signature of Transferee (Buyer): ____________________________ DATE OF STATEMENT: STATE OF WASHINGTON COUNTY OF _______________ SWORN TO AND SUBSCRIBED BEFORE ME, this the _____ day of _______________, 20_____. ____________________________ NOTARY PUBLIC My Commission Expires: ________________________ ORIGINAL MUST BE PROVIDED WITH APPLICATION FOR A CERTIFICATE OF TITLE