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ONE AND THE SAME PERSON AFFIDAVIT

State Form 13637 (R2 / 5-13)
INDIANA BUREAU OF MOTOR VEHICLES

* This agency is requesting disclosure of your Social Security Number in accordance with IC 4-1-8-1; disclosure is mandatory and this record cannot be
processed without it.

INSTRUCTIONS: 1. A person, as defined by Indiana Code §9-13-2-124(a), may present this affidavit to clarify any differences or discrepancies
between an owner(s) name as indicated on a title and/or registration application. This includes individuals and business
entities.
2. Complete in blue or black ink or print form.

ONE AND THE SAME PERSON AFFIRMATION

Name (last, first, middle initial or company name) Name (last, first, middle initial or company name)

Social Security Number* or Federal Identification Number Social Security Number* or Federal Identification Number

Address (number and street) Address (number and street)

City State ZIP Code City State ZIP Code

I swear or affirm that, upon my oath, the information I have entered on this form is correct and the persons named above are one and
the same person. I understand that making a false statement may constitute the crime of perjury.

Signature of Affiant Printed Name Date Signed (mm/dd/yyyy)