Note: If your state requires this document of licensing your boat, please contact Advanced Elements Customer Service Department for completion, or for more information.

MANUFACTURER’S STATEMENT OF ORIGINFOR A VESSEL SOLD IN THE STATE OF_____________________________________

The undersigned manufacturer hereby certifies that the new boat described below, the property of said manufacturer, has been transferred this _________day of _____________________, 20_________on Invoice# _________________to:

Owner’s/Dealer’s Name_____________________________________________________________

Address___________________________________________________________________________

City, State, Zip______________________________________________________________________

Model Name

Model Year

Manufacturer’s Hull Identification#

m FireFly™ Kayak (AE1020)

__________

HIN# ___________________________

Type: Kayak

Hull Material: PVC/Polyester

Length Overall: 7’10”

Beam: 35”

 

U. S. Coast Guard Capacity Plate Information (where applicable): Maximum persons capacity in whole persons: 250 lbs (113 kg) Maximum weight capacity (persons & gear): 250 lbs (113 kg)

The manufacturer further certifies that this was the first transfer of such new boat and that all information given herein is true and accurate to the best of their knowledge

TM

P.O. Box 5128 Concord, CA 94524

Signature_________________________________________________________________________________

FIRST ASSIGNMENT

FOR VALUE RECEIVED, in the amount of $ __________________________________________________, the undersigned hereby transfers the Certificate of Origin and the boat described therein

to _______________________________________________________________________________________

Address __________________________________________________________________________________

and certifies that the boat is new and has not been registered in this or any other state; Advanced Elements, Inc. also warrants the title of said boat at time of delivery, subject only to the liens and

encumbrances as set out below:

 

 

Amount of Lien

Date

To whom Due

Address

___________________

__________

__________________

___________________________________

Dates___________________________ 20 _________, at _____________________ ____________________

___________________________ By:___________________________________________________________

Transferrer (Firm name) Sign Here ___________________________________________________________

Before me personally appeared _____________________________ who by me being duty sworn under oath says the statements set forth above are true and correct. Subscribed and sworn to me before this __________ day of _____________________________ 20 ___________.

___________________________________Notary Public

Date commission expires_______________

(SEAL)