021

FORM 21.

Bill of Sale for an Automobile

(Name of Seller, "Seller" located at: _____ ) in consideration of the sum of $X received from (Name of Buyer "Buyer", specify address), the receipt of which is acknowledged, hereby sells, transfers, and conveys the following personal automobile: (specify model, year, color, make, vehicle identification number, engine serial number) together with the following accessories: (specify). 1. The total price for the automobile is $X which does (or does not) include freight, shipping, delivery, and insurance costs. Payment shall be made as follows: (specify). 2. Seller warrants that he is the lawful owner of the automobile and is selling it free of all liens and encumbrances. The Seller will defend title of the automobile against any claim or demand except any lienholder disclosed in this Bill of Sale. The automobile sold is in good condition with the exception of (specify known defects). While the automobile was in Seller's possession, the odometer was not altered or disconnected and the odometer reading of X miles reflects the actual mileage. 3. Buyer has examined the automobile and purchases it as is. 4. Additional terms and conditions essential to this Agreement include: (specify). Dated: ____________________

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Name of Buyer Dated: ____________________

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Name of Seller State of (specify) County of (specify) On (specify date), before me came (name of Seller), personally known to me to be the individual described hereinabove and who executed the foregoing Bill of Sale, and duly acknowledged to me that he (she) executed the same. _____________________ Notary Public