Signature Date

I certify, under penalty of perjury in the second degree, that the above facts are true and correct to the best ofmy knowledge.

Name

Vehicle Identification Number Year Make Title Number

Statement

STATE OF COLORADO

STATEMENT OF FACT

DR 2444 (05/13/08)COLORADO DEPARTMENT OF REVENUEDIVISION OF MOTOR VEHICLESTITLE SECTIONwww.revenue.state.co.us