MIKE SULLIVAN
Tax Assessor-Collector
STATEMENT OF FACTS
(General)
State of Texas §
County of Harris §
I, the undersigned, hereby certify that:
Vehicle Information:
Year
Make
Vin #
Correct Date of Sale:
Buyer's Name and Address:
Reason for Statement of Fact:
Other:
Signature
Date of Statement
Printed Name (same as signature)
Phone Number
Name of Company, if signing as agent thereof
Please Note: Transportation Code 501.155: FALSE NAME, FALSE INFORMATION, AND FORGERY. (a)
A person commits an offense if the person knowingly provides false or incorrect information or
without legal authority signs the name of another person (b) An offense under this section is a
felony of the third degree.
MV-001-A
www.hctax.net
Rev. 12/14 v.4