APPLICATION AND AFFIDAVIT

FOR DUPLICATE CERTIFICATE OF ORIGIN FOR A VEHICLE (COV)

STATE OF_____________________________COUNTRY OF__________________________

The undersigned (“applicant”) hereby requests CHRYSLER LLC. to issue a duplicate of the Certificate of Origin for
a vehicle (“COV”) issued to applicant for the following described motor vehicle (“vehicle”):

VIN__________________________________MAKE__________________________________

MODEL_______________________________YEAR__________________________________

Applicant states that Applicant is the owner of the vehicle, and that the vehicle’s original CO has been lost, mislaid,
or defaced: that if the CO has been lost, there has been a due and diligent search for the original CO, but it cannot be
found.

Applicant understands that Applicant could be subject to criminal and civil liability for requesting a duplicate COV
for improper purposes. Applicant also understands that CHRYSLER is justifiably relying upon Applicant’s
representations contained herein, in acting upon Applicant’s request.

In consideration of CHRYSLER’S issuance of a duplicate COV, Applicant shall indemnify, defend, and hold
harmless CHRYSLER and its officers, directors, agents, employees, affiliated entities (including but not limited to
subsidiaries), successors and assigns, or, from and against, any and all claims and demands which may be made
against CHRYSLER, whether groundless or otherwise, and for all loss, cost and damage, including all litigation
expenses and attorney fees arising out of, or in any way connected with the issuance of such duplicate COV of by
reason of the original COV remaining outstanding. If Applicant recovers the original COV, Applicant shall immediately
return by certified mail, the original COV to:

Attention: Central Vehicle Invoicing

CIMS 484-00-72
CHRYSLER LLC
800 Chrysler Drive
Auburn Hills, MI 48326-2757

Dated:______________________________ Sworn to and subscribed before me this

Signed:_____________________________ ________day of_______________, 20____

Name:______________________________ ___________________________________
(printed) Notary Public

By:_________________________________ Date Tern Expires____________________

(Title)

____________________________________ State of____________________________

(Name of Dealer)

____________________________________ ______________________County, ss.

(Address in Full)
____________________________________