VSD-332 SPOA 12312021~1.pdf
PDF 240 KB Posted
- Solicitation number
- 27-350SOS-VEHSE-B-53249
- Issued by
- St. Clair County, Illinois
About this file
This document is a proof copy of Form VSD 332.5, the Illinois Secure Power of Attorney, issued by the Illinois Office of the Secretary of State. The form is a four-part carbonless document designed for vehicle title transfer transactions in Illinois. The form contains three primary sections: Part A authorizes a transferee or dealership to disclose vehicle mileage and sign documents required to secure an Illinois title; Part B authorizes a transferor to sign mileage disclosure on the title document; and Part C provides certification when both Parts A and B have been used. The form is restricted to situations where the title is physically held by a lienholder or has been lost. The document requires completion of vehicle description information including year, make, model, body type, and vehicle identification number, along with odometer readings and transferor and transferee signatures with printed names and addresses.
The form includes mandatory federal and state law warnings regarding odometer disclosure and mileage accuracy, with provisions for noting when mileage exceeds mechanical limits or does not reflect actual mileage. The document bears a printed date of August 2021 and reference number 20VS01500, indicating this is a printing proof submitted for review and approval of content, layout, and version prior to production. The proof displays security features including fluorescent ink specifications and logo line configurations for authentication purposes. The form is printed by authority of the State of Illinois and requires submission to the state by the person exercising the power of attorney, with warnings that failure to comply may result in fines and/or imprisonment.
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Other files
| File | Type | Posted |
|---|---|---|
| Secure Power of Attorney Forms IFB B-53249.docx | DOCX document | |
| Vendor Disclosure v 24.1 Formerly Forms A~26.docx | DOCX document | |
| IPG Active Registered Vendor Disclosure formerly Forms B v.23.1~49.docx | DOCX document |
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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)
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(Street Address)
(Date of Statement)
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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.
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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 .