VSD-332 SPOA 12312021.pdf
PDF 240 KB Posted
- Solicitation number
- 27-350SOS-VEHSE-B-52210
- Issued by
- St. Clair County, Illinois
About this file
This is a proof document for a printing specification related to the Illinois Secretary of State's Secure Power of Attorney Form VSD 332.5, a 4-part carbonless form used for vehicle title transfers. The document serves as a print production proof showing the layout, content, and specifications for the secure form, which includes three main sections: Part A for Power of Attorney to Disclose Mileage, Part B for Power of Attorney to Review Title Documents and Acknowledge Disclosure, and Part C for Certification when both Parts A and B have been used. The form contains vehicle description fields, mileage disclosure statements with warnings regarding odometer accuracy, signature lines for transferors and transferees, and security features including fluorescent inks shown in blue and repeated "ILLINOIS" text throughout the document for anti-counterfeiting purposes. The proof is dated August 2021 (8/21) and was printed by the authority of the State of Illinois under print order number 20VS01500 with 1500 copies indicated.
The document is a production proof submitted for content, layout, and version review and does not reflect actual paper or ink matching. The form includes specific security elements such as logo lines, perforation marks (PERF), and repeated state branding to prevent fraud and ensure document authenticity. The proof shows two facing pages with identical form sections arranged head-to-head for efficient printing. No specific pricing terms, bid deadlines, or contract award information is included in this particular proof document; it functions solely as a pre-production specification and verification tool for the printing vendor and the Secretary of State's office.
View the file
Other files
| File | Type | Posted |
|---|---|---|
| Secure Power of Attorney Forms IFB B-52210 Updated Deliverable Dates.docx | DOCX document | |
| Vendor Disclosure v 24.1 Formerly Forms A~20.docx | DOCX document | |
| IPG Active Registered Vendor Disclosure formerly Forms B v.23.1~43.docx | DOCX document |
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Text version
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ATTACH FIRST PART TO CERTIFICATE OF TITLE
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ILLINOIS SECURE POWER OF ATTORNEY
PART A. Power of Attorney to Disclose Mileage
PART B. Power of Attorney to Review Title Documents and Acknowledge Disclosure
PART C. Certification (To Be Completed When Both Parts A and B Have Been Used)
WARNING! This Form May Be Used Only When Title Is Physically Held By Lienholder Or When Title Has Been Lost. This Form Must Be Submitted To The State By The Person Exercising Power(s) Of Attorney. Failure To Do So May Result In Fines And/Or Imprisonment. VEHICLE DESCRIPTION
Year Make Model Body Type Vehicle Identification Number
Federal and State law require that you state the mileage upon transfer of ownership.
Failure to complete or providing a false statement may result in fines and/or imprisonment.
I, (transferor’s name, Print), appoint (transferee’s/ dealership name, Print) as my attorney-in-fact, to sign all papers and documents required to secure Illinois Title and to disclose the mileage on the title for the vehicle described above, exactly as stated in my following disclosure.
I state that the odometer now reads (no tenths) miles and, to the best of my knowledge, that it reflects the actual mileage unless one of the following statements is checked.
(1) The mileage stated is in excess of its mechanical limits.
(2) The odometer reading is NOT the actual mileage. WARNING - ODOMETER DISCREPANCY.
(Transferor’s Signature)
(Printed Name)
(Transferor’s Street Address)
(City, State, Zip Code)
(Date of Statement)
(Transferee’s Signature)
(Printed Name)
(Transferee’s Street Address)
(City, State, Zip Code)
(Part B is invalid unless Part A has been completed)
I, (transferee’s name, Print), appoint (transferor’s name, Print) as my attorney-in-fact, to sign all papers and documents required to secure Illinois Title and to sign the mileage disclosure on the title for the vehicle described above, only if the disclosure is exactly as the disclosure completed below.
(Transferee’s Signature) (Transferee’s Printed Name)
(Transferee’s Name, Street Address, City, State, Zip Code)
Federal and State law require that you state the mileage upon transfer of ownership.
Failure to complete or providing a false statement may result in fines and/or imprisonment.
I, (transferor’s/dealership name, Print), state that the odometer now reads (no tenths) miles and, to the best of my knowledge, that it reflects the actual mileage unless one of the following statements is checked.
(1) The mileage stated is in excess of its mechanical limits.
(2) The odometer reading is NOT the actual mileage. WARNING - ODOMETER DISCREPANCY.
(Transferor’s Signature)
(Transferor’s Street Address) (City, State, Zip Code)
(Date of Statement)
(Transferor’s Printed Name)
I, (person exercising above powers of attorney, Print), hereby certify that the mileage I have disclosed on the title document is consistent with that provided to me in the above power of attorney.
Further, upon examination of the title and any reassignment documents for the vehicle described above, the mileage disclosure I have made on the title pursuant to the power of attorney is greater than that previously stated on the title and reassignment documents. This certification is not intended to create, nor does it create any new or additional liability under Federal or State law.
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(Printed Name)
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Auditor Test
VSD 332.5 Printed by the authority of the State of Illinois (20VS01500) 1500m (8/21)
PERF
(Signature)
(Street Address)
(Date of Statement)
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LOGOLINES READ ILLINOIS.
FACE 1
PROOF 1
This proof is submitted for your review and approval. It is supplied for content, layout, and version review and does not reflect paper or ink match. Please review your proof carefully.
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ATTACH FIRST PART TO CERTIFICATE OF TITLE
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ILLINOIS SECURE POWER OF ATTORNEY
PART A. Power of Attorney to Disclose Mileage
PART B. Power of Attorney to Review Title Documents and Acknowledge Disclosure
PART C. Certification (To Be Completed When Both Parts A and B Have Been Used)
WARNING! This Form May Be Used Only When Title Is Physically Held By Lienholder Or When Title Has Been Lost. This Form Must Be Submitted To The State By The Person Exercising Power(s) Of Attorney. Failure To Do So May Result In Fines And/Or Imprisonment. VEHICLE DESCRIPTION
Year Make Model Body Type Vehicle Identification Number
Federal and State law require that you state the mileage upon transfer of ownership.
Failure to complete or providing a false statement may result in fines and/or imprisonment.
I, (transferor’s name, Print), appoint (transferee’s/ dealership name, Print) as my attorney-in-fact, to sign all papers and documents required to secure Illinois Title and to disclose the mileage on the title for the vehicle described above, exactly as stated in my following disclosure.
I state that the odometer now reads (no tenths) miles and, to the best of my knowledge, that it reflects the actual mileage unless one of the following statements is checked.
(1) The mileage stated is in excess of its mechanical limits.
(2) The odometer reading is NOT the actual mileage. WARNING - ODOMETER DISCREPANCY.
(Transferor’s Signature)
(Printed Name)
(Transferor’s Street Address)
(City, State, Zip Code)
(Date of Statement)
(Transferee’s Signature)
(Printed Name)
(Transferee’s Street Address)
(City, State, Zip Code)
(Part B is invalid unless Part A has been completed)
I, (transferee’s name, Print), appoint (transferor’s name, Print) as my attorney-in-fact, to sign all papers and documents required to secure Illinois Title and to sign the mileage disclosure on the title for the vehicle described above, only if the disclosure is exactly as the disclosure completed below.
(Transferee’s Signature) (Transferee’s Printed Name)
(Transferee’s Name, Street Address, City, State, Zip Code)
Federal and State law require that you state the mileage upon transfer of ownership.
Failure to complete or providing a false statement may result in fines and/or imprisonment.
I, (transferor’s/dealership name, Print), state that the odometer now reads (no tenths) miles and, to the best of my knowledge, that it reflects the actual mileage unless one of the following statements is checked.
(1) The mileage stated is in excess of its mechanical limits.
(2) The odometer reading is NOT the actual mileage. WARNING - ODOMETER DISCREPANCY.
(Transferor’s Signature)
(Transferor’s Street Address) (City, State, Zip Code)
(Date of Statement)
(Transferor’s Printed Name)
I, (person exercising above powers of attorney, Print), hereby certify that the mileage I have disclosed on the title document is consistent with that provided to me in the above power of attorney.
Further, upon examination of the title and any reassignment documents for the vehicle described above, the mileage disclosure I have made on the title pursuant to the power of attorney is greater than that previously stated on the title and reassignment documents. This certification is not intended to create, nor does it create any new or additional liability under Federal or State law.
ILLINOISILLINOISILLINOISILLINOISILLINOISILLINOISILLINOISILLINOISILLINOISILLINOISILLINOISILLINOISILLINOISILLINO
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(Printed Name)
(City, State, Zip Code)
Auditor Test
VSD 332.5 Printed by the authority of the State of Illinois (20VS01500) 1500m (8/21)
PERF
(Signature)
(Street Address)
(Date of Statement)
5 LOGOLINES
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RECTANGLE MADE OUT OF 4 LOGOLINES CONNECTED
XXXXXXXX
LOGOLINES READ ILLINOIS.
PROOF 1
This proof is submitted for your review and approval. It is supplied for content, layout, and version review and does not reflect paper or ink match. Please review your proof carefully.
FACE 2-4
File details come from the government source that posted it. Updated .