KNOWN BY ALL PERSONS BY THESE PRESENTS, that [PRINCIPAL’S NAME] (“Principal”) with a mailing address of [PRINCIPAL’S ADDRESS] grants to [AGENT’S NAME] (“Agent”) with a mailing address of [AGENT’S ADDRESS] or its designated representative for an indefinite period of time or until canceled in writing, a limited power of attorney, to act on its/his/her behalf, with regard to all matters pertaining to the registering, licensing, transfer of ownership, and/or titling of the vehicle listed below with the applicable motor vehicle agency in the State of Pennsylvania.

Year: [VEHICLE YEAR] Make: [VEHICLE MAKE] Model: [VEHICLE MODEL]
VIN: [VEHICLE IDENTIFICATION NUMBER] Odometer: [ODOMETER READING]

Principal’s Date of Birth: [MM/DD/YYYY]
Principal’s Social Security Number: [#]

Principal’s Signature: _______________________ Date: ______________

NOTARY ACKNOWLEDGMENT

State of ______________
County of ______________ ss.

Before me personally appeared the above-named _______________________, (Individual / Company Name) acting as Principal for the above-mentioned vehicle and duly acknowledged the foregoing instrument to be his/her free act and deed in his/her individual capacity or, if the representative of a company, acknowledges that he or she is duly authorized to sign the foregoing instrument on behalf of the company.

Notary Public Signature: _______________________ Date: ______________
Print Name: _______________________
My Commission Expires: _______________________

(Notary Seal)