Mississippi Motor Vehicle Power of Attorney Form

POWER OF ATTORNEY TO TRANSFER MOTOR VEHICLE
This document shall pass with the certificate of title and be included as a support document
to application for new certificate of title and/or application for replacement certificate of title.
Form 78-003-10-1-1-000
THE STATE OF MISSISSIPPI
COUNTY OF _______________________
KNOW ALL MEN BY THESE PRESENT:
THAT I, __________________________________________________________________________________________________
GRANTOR, NAME TO APPEAR IN SAME FORM AS CONTAINED IN CERTIFICATE OF TITLE
________________________________________________________________________________________, OF THE COUNTY OF
(ADDRESS)
________________________________________________________________________and the STATE OF MISSISSIPPI, owner of
the following described motor vehicle, have made, constituted and appointed and by these present do make, constitute and appoint
___________________________________________________________________________________________________________
________________________________________________________________________________________, OF THE COUNTY OF
(ADDRESS)
________________________________________________________________________ and the STATE OF MISSISSIPPI, my true
and lawful attorney, for me and in my name, place and stead to sell, transfer and assign the motor vehicle described as follows to wit:
MAKE____________________________ V.I.N.___________________________________________
YEAR____________________________ BODY TYPE_____________________________________
TITLE NUMBER______________________________
giving and granting unto my said attorney full power and authority to do and perform all and every act requisite and necessary to
transfer and assign the legal title to said motor vehicle to anyone whomever, as may be designated by said attorney.
FEDERAL and STATE LAW requires that you state the mileage in connection with the transfer of ownership. Failure to complete
or providing a false statement may result in fines and / or imprisonment.
I certify to the best of my knowledge that the odometer reading is the actual mileage of the vehicle unless one of the following
statements is checked.
Odometer Reading
(No Tenths)
_____ 1. I hereby certify that the mileage state is in excess of the mechanical limits of
the odometer.
_____ 2. The odometer reading is not actual mileage. WARNING-ODOMETER DISCREPANCY
IN WITNESS WHEREOF I HAVE hereunto set my hand this __________________________day of _______________,
20_______ .
______________________________________________________________________
Signature of Owner, Grantor
______________________________________________________________________
Printed Name of Grantor (if Title is in Company Name, include appropriate Title, Partner, President, Sec. Treas., etc.)
Before me, the undersigned authority, on this day personally appeared_________________________________________________
(Individual Name Only)
known to me to be the person whose name is subscribed to the above foregoing instrument, and acknowledge to me that he executed
the same for the purposes and consideration therein expressed.
GIVEN UNDER MY HAND AND SEAL OF OFFICE THIS________________________day of ________________A.D.,
20________.
________________________________________________________
Notary Public
Title Bureau,
P. O. Box 1383,
Jackson, MS 39215
www.dor.ms.gov
Phone 601-923-7200
Fax 601-923-7224